Risk Management Tools & Resources


CASE STUDY: Failure to Provide Explicit Instructions Results in Poor Outcome for Pediatric Patient

Laura M. Cascella, MA

CASE STUDY: Failure to Provide Explicit Instructions Results in Poor Outcome for Pediatric Patient


The patient in this case was a 2-year-old female. A physician assistant (PA) at a pediatric practice performed a finger stick test on the patient for anemia and lead poisoning. Following the test, the PA applied gauze and a bandage to the patient's finger, and the family returned home. Three days later, the patient's family brought the patient to an urgent care clinic because she was in pain. The child's finger was still bandaged, and it had turned necrotic, requiring a partial amputation.

The patient's parents filed a malpractice lawsuit against the PA and the pediatric practice alleging communication failures and improper performance of a treatment/procedure. The case ultimately was settled with a payment in the mid-range.


This case is fascinating because of its seemingly simple details and lost opportunity to prevent an adverse patient outcome. Yet, it highlights two important issues in patient safety and risk management: communication and documentation.

Communication has long been a safety pitfall in healthcare and a well-documented contributing factor in malpractice lawsuits. Communication problems among healthcare providers (e.g., inadequate handoffs and signouts) and between providers and patients (e.g., failure to follow up or provide appropriate instructions) are not uncommon and unfortunately can lead to serious patient harm.

In this case, the absence of explicit verbal guidance and written follow-up instructions from the PA resulted in the parents leaving the child's bandage in place, which cut off blood supply to her finger and caused tissue death. The assumption that the parents would understand to remove the bandage — because the child would stop bleeding in a short amount of time, and the bandage could impede circulation — was a lapse in judgment by the PA.

What might seem like common sense to one person is not always so to another. Different backgrounds, educational levels, experiences, and so forth can shape an individual's understanding of information. Further, poor health literacy continues to plague effective communication in healthcare. The Agency for Healthcare Research and Quality notes that only 12 percent of U.S. adults have the health literacy skills needed to navigate the complexities of the U.S. healthcare system.

Because low health literacy and poor comprehension are ongoing concerns, healthcare providers should be cognizant of the need to provide patients and parents/guardians with clear, concise guidance, plain-language educational materials, and precise discharge instructions. Additionally, a technique to gauge comprehension, such as "teach-back" or "repeat-back," can help providers determine whether patients and parents/guardians fully understand treatment plans and follow-up care.

The second issue in this case, inadequate documentation, is another common factor cited in malpractice allegations. As part of their lawsuit, the parents in this case included an allegation of improper performance of a treatment/procedure, arguing that the finger stick test was not warranted. The PA claimed that there were indications for the procedure, including several "red flag" symptoms. However, she failed to document her rationale for the testing decision or any differential diagnoses in the patient's health record. These oversights combined with the lack of documentation related to discharge instructions or follow-up care made the case difficult to defend.

In Summary

Thorough communication and documentation are essential elements of a sound risk management strategy. The absence of either or both can result in suboptimal patient outcomes and increased liability exposure for healthcare providers. Although the busy practice environment can undermine providers' attention to communication and documentation issues, periodically assessing and updating strategies and policies can help bring these issues back into focus.

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