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CASE STUDY: Failures in Communication and Management of Care Result in Poor Patient Outcome

CASE STUDY: Failures in Communication and Management of Care Result in Poor Patient Outcome

Theodore Passineau, JD, HRM, RPLU, CPHRM, FASHRM

Case Details

The patient, a 66-year-old Hispanic male who did not speak English, was referred to a MedPro-insured ophthalmologist (Dr. A) by his regular optometrist (Dr. B) for evaluation of early cataracts. During the patient's appointment, Dr. A relied on her very limited Spanish proficiency to communicate with the patient instead of using an interpreter.

An examination revealed that the patient's visual acuity was 20/60 in the right eye and 20/50 in the left eye. His intraocular pressures (IOPs) were 16 in the right eye and 18 in the left eye, both within the normal range. However, his cup-to-disc ratio was .75–.8, which is borderline elevated and can be indicative of glaucoma. Given the reassuring IOPs, Dr. A was not unusually concerned about glaucoma. No other visual field testing was done.

Because the cataracts were affecting the patient's daily life, Dr. A recommended surgery to remove them. Surgery was performed on the left eye first, and it was unremarkable. Dr. B saw the patient the following day, and his visual acuity was documented as 20/400, which is not necessarily concerning on the first postoperative day, especially when a "hazy cornea" was also noted. However, Dr. B noted an extremely increased IOP of 55–70. Dr. B faxed a note to Dr. A's practice regarding the elevated IOP, and that information was conveyed to Dr. A later that day.

Dr. A wanted the patient to come to her office that day so the incision could be "burped" to relieve the pressure. However, because of transportation difficulties, the patient was unable to come for the procedure. As a result, he was started on Combigen® and asked to come to Dr. A's office the following day.

On the second postoperative day, one of Dr. A's specially trained optometrists saw the patient. At that time, his IOP was 18, his visual acuity was 20/200, and corneal edema and haziness were noted. The patient was instructed to continue the Combigen and eye drops that had been prescribed and to return to Dr. A's office in 1 week. Instead of returning to Dr. A's office, the patient went to Dr. B's office the following week. At that time, his visual acuity was 20/200, his IOP was 8, and his cornea was clear. This information was communicated to Dr. A's office, but no one responded.

Five days later, the patient's daughter called Dr. A's office to advise them that her father's vision was still poor since the cataract removal. The staff responded that they would like to see the patient that day, but again, because of transportation problems, he was not seen at Dr. A's office until the next day. At that visit, it was documented that his functional vision was very poor (only able to count fingers at two feet), but his cornea was clear. IOP at that visit was 18 and the cup-to-disc ratio had risen to .8–.9. The examining ophthalmologist (not Dr. A) opined that the poor vision was due to a retinal problem or damage to the optic nerve. An immediate referral was made to a university eye clinic.

The university ophthalmologist was very critical of the care the patient had received and told the patient he was probably now permanently blind in one eye due to Dr. A's mismanagement of the case.

The patient was seen in Dr. A's office about 10 days later. At that time, he was noted to be counting fingers at one foot, had a normal IOP, and a cup-to-disc ratio of .8–.9. Other testing was suggestive of optic nerve damage. The patient was seen in subsequent visits; however, no improvement was noted, and it was accepted that the patient had lost vision in his left eye. The exact etiology of the optic nerve damage was never definitively determined.

A lawsuit was brought against Dr. A and her professional corporation, which, with her consent, was settled in the midrange. Defense costs were also in the midrange.


The first risk factor in this case is poor communication. Research shows that health literacy among the general population is not ideal, and language barriers greatly increase the potential for misunderstanding. Clear communication between Dr. A and the patient was imperative, preferably by means of a professional interpreter. Dr. A's limited Spanish proficiency was not sufficient.

As noted, the cataracts were affecting the patient's daily activities; however, there was no urgency associated with their removal. Given the patient's potential glaucoma (as indicated by the borderline elevated cup-to-disc ratio), Dr. A should have had a detailed discussion with him to discuss the benefits of immediately having surgery versus treating the glaucoma first. This type of discussion is an essential part of the informed consent process, which, in this case, should have been very thorough given the elevated risk factor. Again, this discussion would need to take place using appropriate interpretive services.

Another integral part of the informed consent process is communicating to the patient when (and, if appropriate, where) follow-up appointments will occur after discharge. Asking the patient if he or she anticipates any difficulty keeping these appointments can be useful. Also, the patient should be advised to contact the practice immediately if he or she is unable to keep a follow-up appointment. If this occurs, the practice might determine that it is in everyone's best interest to get the patient in to the office by whatever means necessary, even if it means sending a cab (at the practice's expense) to pick up the patient.

As we know, the patient returned to Dr. B (rather than Dr. A, as directed) the week following surgery. Although his IOP was at 8 and his cornea was clear, his visual acuity was still 20/200. This information was communicated to Dr. A's office but no one responded, suggesting a communication or follow-up lapse within Dr. A's practice.

Further, when Dr. B recognized that the patient's IOP was 55–70 (an alarming elevation), he should have called Dr. A's practice and spoken directly to her. Instead, by the time he faxed his findings to Dr. A and they were communicated to her, much of the first postoperative day was lost. Had a conversation occurred earlier in the day, it is possible that arrangements could have been made to get the patient into Dr. A's office that same day.

The final issue with this case is the criticism of Dr. A's care by the ophthalmologist who subsequently treated the patient at the university practice. Unfortunately, this form of "after-the-fact" criticism occurs more often than it should. Although the patient should never be deliberately deceived, if a subsequent physician observes care that he or she considers inappropriate, the first step is not to communicate this opinion to the patient. The subsequent physician should contact the prior physician and discuss the case with him or her.

If a mistake has been made, it is best for the physician who made the mistake to discuss it with the patient. If the physicians differ in their opinions of how a case should be handled, they should attempt to reconcile their opinions. If they cannot, the patient should be drawn into the discussion. Post hoc criticism rarely benefits either physician.


As the provision of medical care becomes increasingly sophisticated (and therefore complex), it is important to continually attempt to identify and minimize the potential for error in the delivery process. Careful attention to both clinical and nonclinical processes increases the likelihood of a good outcome and improved patient satisfaction.

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