When a 6-year-old boy with a slight fever and thigh pain was brought to an urgent care center for evaluation, there were no red flags for anything ominous. The physician who saw the boy suspected nothing more than an infection, for which she prescribed an antibiotic. When the patient and his parents returned the next day to report that while the fever was gone the boy was still in pain, the physician ordered an x-ray. At first glance, there appeared to be nothing remarkable. Unfortunately, the case took a dark turn at this point. While the urgent care operator’s policy was to send x-rays out for expert evaluation, this was never done. Months later, after multiple follow-up trips to the emergency room and the pediatrician’s office, the boy had a sizeable lesions on his femur; he was diagnosed with Ewing sarcoma. The boy’s family sued the urgent care operator, alleging that its failure to have the first x-ray evaluated adequately delayed diagnosis and proper care. While the boy has survived, to date, and the outcome of the lawsuit remains to be seen, the lesson is painfully clear: Protocols, policies, and standard operating procedures exist for a reason. While the priority is always to ensure excellent, thorough care, deviations leave the urgent care center wide open for litigation and blame.

The Risk of Ignoring Clinical Policies Is Real—and Can Be Severe for Patients and the Practice