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When Specialist “Hop Scotch” Can Lead to Mishaps

Posted By Administration, Wednesday, December 28, 2016
Updated: Wednesday, December 28, 2016

The National Patient Safety Foundation recommends that patients make sure that all of their doctors know about every medicine they are taking. 

by Michael Kelleher, MD


The following is a true story that involved a close relative of mine. For the sake of argument, we’ll call him “Mr. K.”


Mr. K. underwent surgery for colon cancer, complicated by a prolonged recovery with poor appetite, bloating, and persistent abdominal discomfort. At the same time, he was undergoing treatment for rheumatoid arthritis. His arthritis specialist had prescribed prednisone tablets at 10mg daily. There was no communication, however, between the surgical and arthritis specialists. In addition, the primary care physician (PCP) had not yet received a rheumatology note listing the new prednisone medication.


"Specialists usually have no idea

who else is treating you unless you tell them."

Mr. K returned three times to the surgical office with his post-operative complaints. He was advised that infection was unlikely because he had no fever. But, Mr. K’s prednisone therapy was masking his fever and the signs of inflammation in his belly. After another week of misery at home, he took himself to the local emergency department where he was noted to have dangerously low blood pressure and a CT scan that showed a very large abdominal abscess.


This near-fatal delay in appropriate care was the result of poor communication among the patient's three treating physicians. This is, unfortunately, a common occurrence in our fragmented health care system. Although some large multispecialty group practices have electronic health records (EHRs) that are shared across all clinical offices, most private offices do not share a common EHR platform and do not communicate electronically with all the other clinicians who are treating you. In fact, specialists usually have no idea who else is treating you unless you tell them.


Download the Medication Wallet Card from NPSF or read more about medication safety on the AHRQ website.


Boosting communication

In this scenario, we can all agree that more than just one thing went wrong, but when it comes to medication, everyone involved in your care needs to be on the same page. The National Patient Safety Foundation, the Agency for Healthcare Research and Quality (AHRQ), and others recommend that patients make sure that all of their doctors know about every medicine they are taking. This includes prescription and over-the-counter medicines and dietary supplements.


Even if the medical office staff does not specifically ask for this information, provide it and ask that it be included in the specialist records. This can reduce the likelihood of an adverse event like what happened to Mr. K.


Other things patients can do to promote safe care:


Inform clinicians of all treatment plans

Take a minute to call your PCP’s office staff to inform them of any treatment plans proposed or implemented by other clinicians. In theory, the PCP will eventually receive a mailed letter from the specialist with that information, but this is not a guaranteed process, and may not happen for several weeks.


Update your electronic health records

Most of these EHRs include patient portals, which give patients online access to their primary care site. This is a convenient way to update your PCP’s office (without struggling to get through on the phone) regarding care that you have received elsewhere.


When it comes to communicating with your health care providers, never assume that they know what another clinician has ordered for you. Always share the details.



This post was adapted with permission from Avoidable Medical Mishaps: A Patient Guide.


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  Michael Kelleher, MD, past member of the Mass Medical Society's Quality of Medical Practice Committee, has 34 years of experience as a physician and medical executive responsible for patient safety and quality of care in large group practices.


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