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
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