A female patient with signiﬁcant osteoporosis suffers a hip fracture. She is 61 and has a long history of smoking and hypertension that is controlled by medication. Following the discovery of the hip fracture, the emergency physician orders a chest x-ray and admits her to an orthopedic physician. The patient does well with her ORIF and is discharged.
Neither the emergency room physician nor the orthopedist review the chest x-ray and report. Copies are sent to the primary care physician and are ﬁled in the chart without the physician's review.
The primary care physician continues to see the patient for hypertension, well-woman care, and acute illnesses. Nearly 21 months later, the patient suffers hemoptysis, and the physician orders another chest x-ray. The physician receives the report for this ﬁlm consistent with a large mass in the right upper lobe. At this time, she notes in the chart that the previous chest x-ray showed a smaller but apparent mass in the same position. The radiologist’s report for the prior scan was accurately interpreted as abnormal and suggested a follow-up CT scan of the chest.
All of the physicians involved in this case study were named in a lawsuit for failure to diagnose lung cancer for a period of 21 months. The cancer is now metastatic and the patient is thought to be terminal. It is alleged that had the report been acted upon earlier, the tumor may have been resectable and the patient would have a better prognosis. The following summarizes the allegations:
- The emergency physician ordered the study so his name appears on the report. It is alleged that he failed to review the study and relay the information to the subsequent provider.
- The orthopedist’s name is also included in the chest x-ray report and appeared in the hospital chart. He is named in the suit for not communicating the information to the patient or following up.
- The primary care physician is named in the suit as she saw the patient on several occasions during the delay period, and her chart contained the positive chest x-ray report—ﬁled yet not initialed.
- The radiologist who saw the obvious mass and correctly interpreted the report is named for not further communicating the ﬁnding to the other three physicians.
We see system failures in which critical pieces of information, such as an image report, a critical lab value, or a signiﬁcant consultation recommendation, were not subsequently communicated to the patient or acted upon. While it might seem unfair to all the physicians for failing to “rescue” the situation, all had an opportunity at different levels to see, act on, and communicate the serious abnormal ﬁnding.
Some risk management advice:
- Remember, if you order a study, you own it.
- If a critical lab result comes to your ofﬁce, the information should be reviewed and appropriate follow-up documented before it is ﬁled. We strongly recommend each ofﬁce have a standardized manner in which information ﬂows to the provider. Everyone in the ofﬁce should be aware of the process, and the provider should have a standardized method for indicating the review, such as initialing the paper report (if the record is electronic, use an analogous method). This will ensure that the report is not ﬁled prior to the provider’s review.
Created by MagMutual from materials provided by COPIC as part of MagMutual and COPIC’s alliance to improve patient safety and quality of care for all of our PolicyOwners.