Risk Management

Failure to Coordinate Follow-up Care Results in Missed ROP Diagnosis

Digest, Summer, 1995


Failure to communicate responsibility for scheduling a follow-up examination of a premature baby after discharge led to delayed diagnosis and treatment of retinopathy of prematurity (ROP), resulting in bilateral blindness.


Joint settlement was reached with indemnity equally divided among the neonatologist, the ophthalmologist, the hospital, and the attending pediatrician.


Communication between attending and consultant physicians is a critical aspect of patient care. When responsibility for follow-up is not clearly defined between specialties, the patient may be lost to follow-up if there is a communication failure within the health care team.

Case Summary

A premature baby boy weighing 1200 grams (2.6 pounds) was delivered by caesarean section at 29 weeks gestation. An ophthalmology consult was called and the eye examination was noted on the chart as “ROP I nasal and temporal retina, zone 2 to 3, mild. Should resolve. Recheck 4 weeks.” The ophthalmologist used an older staging system in which Stage I refers to abnormal vessel configuration, rather than a pre-demarcation line condition. He later explained that his examination of the infant revealed a pre- Stage I or Stage O condition, which has no staging description according to the “new” classification system for ROP, which became the standard of care in 1984-four years before this baby was born-Stage I ROP is characterized by a demarcation line. Thus, under the newer classification system the findings from this exam would not have qualified for a staging classification. The ophthalmologist later stated that the four-week follow-up recommendation was based on the “lack of a demarcation line” on exam and that he would have set an earlier recheck date had there been a clearer line of demarcation.

It was the policy at this neonatal unit for the neonatologist to make arrangements for any scheduled follow-up visits for patients while they were in the unit. But once a patient was transferred, the individual consultants were expected to follow up on recommended care. No arrangements were ever made for the four-week ophthalmology recheck, and the child was discharged one week before he should have been seen for the recheck. Additionally, the neonatal unit, which usually completed a discharge planning form to check off whether all consults were done and confirm that follow-up was scheduled, never completed a form for this baby so the ophthalmology recheck exam was never scheduled.

Upon discharge, the infant was followed by a pediatrician, who did not examine the baby for ROP and thus was unaware of the condition until she received the hospital’s discharge summary at her office three months later. She then discovered this ophthalmology reference: “It should be noted that the baby was seen by ophthalmology to rule out ROP and that exam was noted as Stage I, although I cannot at this time find the consult note. He should probably follow up with this infant after discharge.” The attending physician immediately referred the baby to the ophthalmologist who diagnosed Stage V ROP. Referral was made to a retina specialist who confirmed the diagnosis and performed two surgeries on the left eye and one on the right. None of the surgeries were successful, and the infant became totally blind.


Each institution has its own rules and policies regarding delegation of duties and responsibility for referral and follow-up of patient care. In this case, there was confusion between the ophthalmologist and the neonatologist over who was responsible for the baby’s follow-up care. The referral pattern established between the attending neonatologist and the consulting ophthalmologist was one of the major issues raised by the experts who reviewed this case. The ophthalmologist stated at his deposition that the neonatologist had not wanted him to contact the parents and that she would contact him to request all consultations with the patient. The neonatologist testified that she considered herself responsible for arranging follow-up appointments with consultant physicians while an infant remained in the hospital, but it was the consultant’s responsibility to follow through with a charted follow-up appointment once the infant was discharged. It was not difficult for the plaintiff’s attorney to convince the jury that each of the caregivers in this case had failed in their responsibility to coordinate follow-up care, and that this failure prevented a timely diagnosis of ROP.

Defense of the case against the ophthalmologist was further hampered by reference to both an “old” staging system and a “new” system in his report of the baby’s first eye exam. It was not clear what the ophthalmologist meant by this until he explained his peculiar reference system at his deposition. Even more damaging to the credibility of the recorded findings was expert testimony that the first ophthalmic exam is often inaccurate due to the difficulty of examining a squirming infant. For this reason, a follow-up exam is generally completed within one to two weeks to confirm the initial findings. This set the stage for the plaintiff to allege that the consulting ophthalmologist not only failed to accurately examine the infant and diagnose ROP on the first exam, but also failed to do a timely follow-up.

Risk Management Principlesand Commentary

With all pre-term infants, a careful delineation of the responsibilities of the hospital, the neonatal ICU, the neonatologist, and the ophthalmologist must be developed. This case points out the need for communication between the ophthalmologist and the parents during the first examination of an infant for ROP. Parents should be educated about the possibility of blindness in their pre-term infant and a reexamination appointment should be made at the time of the first exam. If this appointment is not kept, the ophthalmologist’s office should contact the parents with a timely phone call and registered letter reminding them of the missed appointment and the need for follow-up care.

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