The High Cost of Hanging Up Before Conveying Test Results

A 31-year-old single mother visited her primary care physician with pain in her ankle and calf. The next day she underwent radiography and a Doppler ultrasonography scan of her calf and was told to call her primary care physician (PCP) for the results.

The radiologist reviewed the images and diagnosed deep vein thrombosis, putting the patient at risk of pulmonary embolism. He immediately called her primary care physician but was put on hold after reaching the HMO’s automated phone system. Finally, in frustration, he hung up the phone. Rather than calling back, he prepared a fax with the information and a diagram of the patient’s calf indicating the problem, and gave it to an assistant to fax to the PCP.

After calling the PCP and being told that her radiography results were not in yet, the patient missed her follow-up appointment and was found dead at home a day later. The cause of death was a pulmonary embolism.

Which physician is at fault?

(Discussion on next page)