Dialogue Volume 15 Issue 1 2019 - Page 39

PRACTICE PARTNER PATIENT SAFETY We use this forum to regularly report on findings from patient safety organizations, expert review committees of the Office of the Chief Coroner, and inquests. Chief Coroner raises continuity of care concerns in patient case P hysicians are reminded of the importance of informing patients of critical test results in a timely manner, says a committee of the Chief Coroner’s Office. The reminder is prompted by the Patient Safety Death Review Committee’s investi- gation into the death of a man after con- cerns were raised about emergency room management of his care. Specifically, the concerns focused on a failure to inform the patient of test results obtained at Hospital A and the inability of Hospital B to access laboratory test results from other institu- tions through the Ontario Laboratory Information Service (OLIS). The patient was a 68-year-old diabetic male with a history of nephrolithiasis, dyslipidemia, aortic valve stenosis and coronary artery disease. In May 2014, he underwent triple vessel coronary artery bypass surgery and aortic valve replacement with a bioprosthetic valve. The patient arrived at Hospital A on December 6th, 2015 with an eight day his- tory of fever, chills, lethargy, diarrhea and vomiting. Several laboratory investigations, including blood cultures, were obtained during this hospital visit. The patient was discharged with a diagnosis of gastroenteri- tis and fatty liver, and advised to consume a dairy-free low fibre diet. While instructed to return if he did not improve, it does not appear that this information was communi- cated to the patient’s family. On December 9th, 2015, the patient’s ISSUE 1, 2019 DIALOGUE 39