Failure to diagnose and address cardiac event monitor findings significantly contributed to morbidity and mortality, based on an analysis of closed cardiology malpractice claims by The Doctors Company. In this case, poor documentation, lack of follow-up, delay in addressing findings, patient nonadherence, communication issues and lack of intervention before discharge contributed to the poor patient outcome, highlighting the importance of immediate intervention and follow-up care.

Allegation and Background

The cardiologist's failure to properly diagnose and address the significant events captured on a cardiac event monitor over time contributed to the patient's death.

A patient with a history of hypertension, peripheral artery disease and femoral/iliac artery stents was scheduled for elective surgery. A preoperative electrocardiogram (ECG) revealed a bifascicular block and first-degree atrioventricular (AV) block, which was communicated to the surgeon and documented in the electronic health record. During surgery, the patient experienced a third-degree heart block that required medication intervention to stabilize.

A cardiologist was consulted postoperatively and noted progression to a third-degree heart block. The cardiologist ordered a transthoracic echocardiogram (TTE) and a cardiac event monitor (EM). Before the TTE result was available, the patient was discharged home with instructions to follow up in the clinic in two weeks. The TTE result read by the cardiologist after discharge revealed an ejection fraction (EF) of 25-29% and a moderately sized right atrial mass. The cardiologist planned to discuss these results with the patient at the next appointment but did not document this.

The EM recorded multiple auto-triggered events, including many instances of ventricular tachycardia (VT), occurrences of second-degree type 2 heart block, a high volume of premature atrial contractions and premature ventricular contractions (PVCs), with a PVC burden of 2%. The patient presented for the cardiology clinic appointment but left before being seen due to long wait times. The appointment was rescheduled for three months later (first available time).

The clinic uploaded the EM findings three weeks later, but the cardiologist did not overread the results until six weeks later, revealing a type 2 block with multiple episodes of nonsustained VT and several episodes of 2:1 AV block. However, the cardiologist's staff left a voice message advising the patient that there were no new changes on the EM and to keep the scheduled appointment.

Before the appointment, the patient was found unresponsive, having suffered a STEMI with severe hypoxic-ischemic encephalopathy. Cardiac catheterization revealed triple-vessel disease with 85-90% stenosis in three to four major vessels. The patient passed away a few days later.

Commentary

Several factors contributed to this fatal outcome:

• The preoperative ECG suggested a biifascicular block and first-degree AV block, requiring prompt evaluation and care.
• The TTE results were not acknowledged or documented. The reduced EF may have led to one or more urgent procedures.
• The EM recorded significant cardiac events, but the results were not reviewed until six weeks later. The serious findings needed to be escalated to the cardiologist as soon as they were detected. The voicemail from staff regarding benign EM findings was inappropriate.
• Multiple members of the care team missed multiple opportunities to recognize and act upon the patient's urgent clinical condition.
• The patient left a follow-up appointment due to long wait times, and a three-month wait for a rescheduled appointment demonstrated a lack of clear communication regarding the urgency of follow-up care.

Patient Safety Considerations

Potential clinic systems or process improvements include:

• Improve documentation and follow-up: Review and document all test results before patient discharge. Documenting the clinical rationale for actions taken or not taken based on the results serves as communication among practitioners while also supporting and defending treatment decisions.
• Timely review and act on critical findings: Execute signed agreements with EM vendors to systematically identify and communicate EM "red alert" rhythms for immediate review by the practice. Review system implementation quarterly to ensure proper function and documentation of the alert and actions taken.
• Build redundancy in communication: Create structured communication pathways to ensure team members are alerted when results, messages and appointments are not timely acted upon.
• Enhance patient communication and appointment management: Improve the consistency of communication with patients regarding the urgency of follow-up care and appointments. Adjust scheduling to reduce waiting times to prevent patients from leaving appointments without being seen. Include practitioner review of all missed appointments without immediate reappointment to determine which patients require follow-up within a designated time frame.
• Increase care coordination: Establish a robust system for monitoring patients after discharge and ensure timely follow up on test results and appointments. Leverage the capabilities of your EHR and any fully vetted AI tools used in your practice to close the loop on these care opportunities.
• Provide training: Educate practitioners and staff on documentation, reviewing critical findings, patient communication and care team coordination. See the Agency for Healthcare Research and Quality's TeamSTEPPS® program (AHRQ.gov/teamstepps).

Keywords: Cardiology Magazine, ACC Publications, CM-Apr-2026, Malpractice, Morbidity, Wearable Electronic Devices