Practice of Medicine

Claims Lesson

Absence of a Test Tracking System Contributes to a Delay in Diagnosis of Squamous Cell Carcinoma

November 26, 2013

The patient’s dermatologist removed a subcutaneous mass on her right cheek and sent the tissue specimen to pathology. However, the physician never saw this pathology report. Later, at the time the plaintiff requested the medical records, the pathology report was discovered. It had not been initialed and was not mentioned in any of the physician’s progress notes. That particular report was dated exactly two days after the lab received the tissue and indicated that the cancerous lesion was not completely removed. The report read, “cancer remains at the deep margin.”

A week later at her first post-operative visit, the patient complained the operative site was draining. The dermatologist presumed this indicated infection and recalled during deposition that she wanted to eliminate it before performing any further excision of the area. However, her thoughts about clearing up the infection before further excision of the site were never documented. No culture reports were found in the record either.

The patient made multiple visits to the dermatology office for the next ten months, returning to the office for excisions of growths on her forehead, nose, and left arm.

Eight months after excising the mass from the patient’s right cheek, the dermatologist further excised tissue from the original excision site. As with all of the other specimens, the tissue was sent to pathology. The findings were reported seven days later and read, “The lesion extends to one lateral margin of this section.”

Again, no mention was made of either of the two surgical pathology reports from the right cheek excisions. A month later, the patient returned to her dermatologist for the last time. She presented for another evaluation of the area on her right cheek, complaining that the wound was not getting any better. The dermatologist diagnosed an epidermoid cyst in the left cheek and changed the patient’s antibiotics. In addition, she instructed the patient to use hot compresses. At this point, the patient went for a scheduled check-up with her primary care physician.

At the end of the month the dermatology office received a call from a surgical oncologist requesting the patient’s medical records, indicating that the dermatologist had made the referral. The dermatologist’s records did not indicate that she had made the referral.

The patient underwent radiation, total parotidectomy with disfigurement of her face.


Delay in diagnosis and failure to treat squamous cell carcinoma.

Disposition of the Case

The case was settled for a moderate amount.

Risk Management Commentary

The physician’s poor diagnostic report tracking system was one of the primary issues in this case, along with the physician’s failure to document her rationale for the treatment plan she undertook with this patient.

Regardless of whether you use an electronic health record or maintain paper charts:

  • Track test results and diagnostic reports until the results have been received and you have signed /dated your review.
  • Notify patients of the results.
  • Document the notification.
  • Ensure that patients with abnormal results receive the recommended follow-up care.
  • Document your rationale for any treatment plan you undertake.


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