A 51-year-old woman with a high concentration of fats in the blood and a family history of heart disease asked her longtime primary care physician (PCP) for a referral to a cardiologist. Although her doctor’s office reports having sent the referral, she never received it. After numerous calls to her PCP, the woman finally — three months after her initial request — had a cardiology appointment scheduled. She died of heart failure the day of the appointment.
This case, which malpractice insurer CRICO reports was settled for $150,000, is a disturbing example of a physician referral process that is rife with the potential for miscommunication and harm to patients. Concerned about the number of cases of missed or delayed diagnoses related to snags in the referral process, CRICO funded a recent report from the Institute for Healthcare Improvement/National Patient Safety Foundation designed as a call to action to standardize the complex process.