AHRQ WebM&M: Morbidity & Mortality Rounds on the Web
No News May Not Be Good News 
Commentary by Carlton R. Moore, MD, MSThe Case | |
A 10-year-old girl with a history of asthma was brought by her mother (a nurse) to see a pediatrician because of a 15-pound weight loss over a period of 3 months. There were no notable changes in the child's diet or urination and there were no other systemic symptoms. A physical examination was unremarkable and the pediatrician ordered basic labs on a Thursday morning.
On Monday morning, the patient's mother called the pediatrician's office to obtain the results of the blood tests. The pediatrician was busy all day long but near the end of the day found the result. He was shocked to learn that the patient's blood sample, drawn on Thursday, had a glucose level of 320 mg/dL (normal random blood sugar: 70–125 mg/dL).
The pediatrician immediately contacted the mother and had her bring her daughter to the office. A repeat stat blood test showed that the patient's blood sugar was now 450 mg/dL and she had moderate ketones on a urinalysis (showing early signs of diabetic ketoacidosis, which can be life threatening). She was given insulin and specific instructions on management at home. The patient and mother had to return to the clinic each day for the next few days for ongoing management. The patient did not experience any long-term consequences.
When reviewing the case, the pediatrician was surprised that no one had been notified about the elevated blood sugar level. He came to learn that a fax of the laboratory results had been sent to the clinic on Saturday with the urgent result, but, for unclear reasons, the physician covering for the weekend never saw the result. This clinic did not have an electronic medical record (EMR).
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