Multi-Agent Handoff Drops Specialist-Noted Contraindication Before Care-Plan Finalization

Issue: A Specialist-Consult Agent That Identifies, in Its Own Consult-Note Reasoning, a Contraindication to a Specific Treatment Approach Hands That Finding Off to a Primary Treatment-Planning Agent Through a Structured Consult Summary That Has No Field for Contraindications, So the Treatment-Planning Agent Finalizes a Care Plan Including the Approach the Specialist Had Ruled Out

Frequency: Occasional

Symptoms

• The specialist’s consult note pairs a real clearance with a specific condition attached to it – avoid this one technique – but the structured recommendation field the treatment-planning agent reads only ever encodes “cleared” or “not cleared,” with no slot for a condition riding along with a clearance
• The treatment-planning agent’s output looks complete and clinically unremarkable on its own, since a plan using the ruled-out technique doesn’t look wrong without also having the specialist’s note in view
• Every other consult of this type that the treatment-planning agent has processed used the recommendation field as an unconditional signal, so there is no precedent in its own history that would prompt a check for a hidden condition
• Anesthesia or nursing staff catch the conflict only by manually re-reading the full consult transcript shortly before the procedure, not through any automated check
• The same gap would recur for any conditional clearance, not just an anesthesia technique – a medication contraindication or an activity restriction attached to an otherwise-clearing consult would be dropped by the same binary field

Root Cause The consult-summary schema’s recommendation field was built around a binary clinical question – is this patient cleared for the procedure – because that is what the treatment-planning agent needs in the overwhelming majority of consults. A conditional clearance, where the patient is cleared only if a specific technique is avoided, doesn’t fit that binary shape: the specialist agent still writes “cleared,” because the patient genuinely is clearable, and the condition attached to that clearance has no field of its own to occupy. The treatment-planning agent’s plan-generation step reads the recommendation field literally, as an unconditional green light, because every other consult it has processed used the field that way.

Example

Specialist-consult agent reviews a patient's cardiology workup ahead of a planned orthopedic procedure, noting: "Patient's recent stress test shows findings that contraindicate the standard regional anesthesia approach typically paired with this procedure; general anesthesia protocol should be used instead"
Specialist agent's structured consult summary handed to the treatment-planning agent includes only a general recommendation field: "Cleared for procedure with cardiology monitoring"; no contraindication field exists in the schema
Treatment-planning agent finalizes the care plan using the standard regional anesthesia approach, the exact approach the specialist's consult note had ruled out
Anesthesia team discovers the contraindication only when manually reviewing the full cardiology consult note shortly before the procedure, requiring a late plan change

Key Statistics

Contributing Factors

• The consult-summary schema has a general recommendation field but no dedicated, structured field for patient-specific contraindications identified during the consult
• The treatment-planning agent’s plan-generation process consults only the structured consult summary, never the specialist agent’s full consult-note transcript
• No reconciliation step compares contraindication language in the specialist agent’s consult note against what the structured summary actually encodes before the care plan is finalized

Mitigation Strategies

1. Structured Contraindication Field in Consult-Summary Schema: Extend the consult-summary schema to carry an explicit, mandatory-to-populate contraindication field, and require the specialist-consult agent to write any patient-specific contraindication directly into it rather than leaving it in narrative consult-note form only
2. Mandatory Pre-Finalization Contraindication Check: Before a treatment-planning agent finalizes a care plan, require an automated check of the structured contraindication field from any relevant specialist consult, blocking finalization on any unresolved discrepancy
3. Consult-Note-to-Summary Reconciliation Pass: Run an automated pass comparing every contraindication-related statement in the specialist’s consult-note transcript against the structured summary, flagging any contraindication mentioned in the note but absent from structured fields
4. Treatment-Planning Agent Access to Full Consult Rationale: Require the treatment-planning agent’s plan-generation step to have direct access to the specialist’s full consult-note transcript, not only the structured summary, for any case involving a specialist consult

Metrics

• Rate of care plans where a relevant specialist consult note contains contraindication language not reflected in the structured consult summary
• Rate of care-plan changes required late in the planning process due to a missed specialist-identified contraindication
• Time between contraindication identification during consult and its incorporation into the structured consult summary

Alerts

• A care plan is finalized including an approach a specialist consult note explicitly identified as contraindicated → P1
• A specialist consult note contains contraindication language not reflected in the structured summary before care-plan finalization → P2
• Contraindication-reconciliation mismatch rate exceeds the defined threshold for a rolling window → P2

References

• Why Do Multi-Agent LLM Systems Fail? (MAST)
• MedAgentAudit: Diagnosing and Quantifying Collaborative Failure Modes in Medical Multi-Agent Systems
• Tiered Agentic Oversight: A Hierarchical Multi-Agent System for Healthcare Safety