Failure to Follow Up and Report Incidental Findings to Patient Is a Breach of Standard of Care

Allegation:

PAs and primary care physician’s failure to follow up on incidental lung findings in CT angiogram (CTA) report resulted in a one-year delay in diagnosis of adenocarcinoma of the lung and death.

Case Details

A 71 YOF with a history of left carotid arteriosclerosis and being a long-time pack-a-day smoker presented to her primary care practice for her annual exam. She was seen by PA #1, who noted a right-sided carotid bruit and referred her to an interventional cardiologist. The cardiologist ordered a CTA of the carotid arteries which showed bilateral internal carotid artery stenosis. Monitoring was recommended. At the end of the report, it noted numerous ill-defined ground glass infiltrates and a 1.5 cm x 1.5 cm soft tissue density in the right lung apex. Follow up with CT chest was recommended.

The radiologist discussed the CTA findings with the PCP, not the cardiologist who ordered the test. The report was signed by PA #2, who didn’t review it. The PCP couldn’t recall the conversation but scheduled an appointment with the patient, who ended up seeing PA #1. PA #1 acknowledged during her deposition that the standard process was to read the complete radiology report—all findings—and discuss these and any recommendations with the patient. She could not recall why she did not follow this process on the day she met with the patient. The cardiologist’s notes mentioned the initial CTA results—including incidental findings—but there was no record that the patient was informed. The cardiologist claimed he told the patient to follow up with her PCP, which the patient denied.

One year later a follow up CTA was ordered by the cardiologist to monitor the carotid artery stenosis. The study showed stable carotid stenosis but progressive disease was seen in the lung nodules. The PCP called the patient to inform her of all findings and ordered the recommended chest CT, which revealed a new right thyroid nodule and persistent soft tissue density in the right upper lobe. He ordered a PET CT which indicated widespread disease. The patient underwent left upper lung bronchoscopy with biopsy confirming a diagnosis of Stage IVa, non-small cell adenocarcinoma of the lung. She underwent extensive chemotherapy but died nine months later.

Expert Testimony

Plaintiff and defense experts both felt that the patient’s PCP, the interventional cardiologist, and both PAs were negligent and breached the standard of care in not informing the patient of the lung findings and not ordering the chest CT recommended on the initial CTA exam. No one could support the practice’s policy of approving test results without review either. Experts for the primary care group felt that the interventional cardiologist—as the ordering physician of the original CTA—had a non-transferable obligation to follow up. Defense experts for the interventional cardiologist argued that the primary care providers—as the coordinators of care—were responsible for follow up.

Resolution

The case settled during trial. Since it was not disputed that both PAs, the PCP, and the interventional cardiologist breached the standard of care the case hinged on a causation defense—an argument challenging the claim that the breach of care caused the patient’s death. This proved difficult with mixed expert reviews and the patient expiring prior to her deposition. Additionally, the co-defendant cardiologist made a poor witness, finger pointing and blaming the primary care clinicians and the patient for lack of communication.

Risk Reduction Strategies

The following best practices can help enhance patient safety and reduce your liability risk in the event of incidental findings:

• Develop an incidental findings process:
  • Develop clear policies for managing findings and tracking procedures; Develop standardized criteria to categorize incidental findings that need immediate action or require follow up as high priority.
  • Conduct regular audits to review how incidental findings are managed and resolved. Identify any gaps in the process and implement necessary improvements.
  • Standardize protocols for documenting incidental findings including highlighting incidental findings in reports.
• Communicate directly with the referring provider and your supervising physician, if applicable, once results are received, especially if the results are significant or follow up is needed.
  • Prioritize unexpected or critical findings with direct handoff of care with the ordering or primary care physician. Determine who will be responsible for informing the patient.
• Ensure patient awareness by using plain language and closed-loop communication. This means the clinician informing the patient of test results should discuss all findings and follow-up steps and ask the patient to repeat back what they have heard to confirm understanding.
• Document in the medical record all incidental findings, recommended follow-up steps, and the discussion with the patient. Include the information provided and name of the clinician responsible for managing follow up care.
• Do not sign off on or accept any testing, lab work or imaging results that you have not fully reviewed.

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If you have questions on this topic, please contact us at RiskAdvisor@ProAssurance.com or 844-223-9648.