In the following case, reporting and communication of discrepancies and incidental findings were critical factors in the negative outcome.
Allegation
Failure to report an incidental finding resulting in delayed diagnosis of metastatic lung cancer and death of a 27 YOF.
Case Details
A 27 YOF presented to her local ED with complaints of SOB and 3/10 sharp chest pain radiating to the shoulder, exacerbated by walking and deep breaths. The patient had no significant clinical history and was a nonsmoker. She reported she was on birth control pills for about a month; and denied cough, fever, nausea, vomiting, and diarrhea. Her vital signs were stable with a temperature of 98.4 degrees, pulse at 100, respirations at 16, and blood pressure of 128/90. Pulse oximetry was 99%. The ED physician ordered multiple tests including a chest x-ray, lab work, and an EKG. The chest x-ray showed a faint appearance of possible pneumonia. The EKG showed normal sinus rhythm, and lab work was normal. Because the patient was on oral contraceptives, the ED physician ordered a CT scan of the chest to assess for pulmonary embolism (PE).
The initial findings of the CT were negative for PE and confirmed the pneumonia in the left lower lobe. The ED physician reviewed the results of the CT and discussed the findings with the patient. Other testing resulted as normal. The patient’s chest pain and SOB had subsided, and the patient was discharged home in stable condition with a diagnosis of musculoskeletal pain. The patient was instructed to take ibuprofen as needed for pain and instructed to follow up with her PCP in two to three days, and to return to the ED should the symptoms return. The patient was not prescribed an antibiotic as she did not have a cough or a fever.
Post discharge, the radiologist on call overread the chest CT and found confluent density suggestive of pneumonia. He also noted some nodular configuration that was likely due to the lung consolidation rather than a mass. The radiologist dictated a recommendation for the patient to follow up and copied the ED physician on the report. This recommendation was not called to the ED physician, nor was it communicated to the patient or her PCP.
The patient did not seek any further treatment for her symptoms and continued to be symptom free for the next three years and her annual physicals with her PCP revealed clear lungs upon auscultation. After those three years her chest pain returned, and she complained of shortness of breath with rattling and a raspy voice. On examination of her lungs, there was a presence of wheezing, and rales on the left side. A chest x-ray revealed pneumonia with density in the left lower lobe which likely represented atelectasis or infiltrates. A CT with contrast was performed and revealed persistent multifocal alveolar infiltrates with dense consolidation in the left lower lobe, eosinophilic pneumonia, aspiration pneumonia, acute interstitial pneumonia, and infectious pneumonia or possible hemorrhage. The patient underwent a bronchoscopy with biopsies of the lung. Pathology revealed stage IV lung adenocarcinoma. The patient underwent chemotherapy, but ultimately the disease progressed and metastasized to the brain and bone. She expired three years later.
The husband of the patient filed suit against the on-call radiologist, the ED physician, and the hospital.
During deposition, the defendant testified that when there is a significant discrepancy between the interpretations, he would make a phone call to discuss the discrepancy. However, he stated that he and the initial radiologist agreed with the diagnosis, and he identified a further incidental finding but that is not necessarily a discrepancy that would require a telephone call for discussion with the other radiologist or to the ordering physician.
Expert Testimony
The defendant expert radiologist testified that a call to the ordering physician is only required by the standard of care when there is an unexpected or urgent finding that needs to be communicated to the ordering physician. The pneumonia had already been communicated; therefore, there was no need to phone the result to the ordering physician. The nodular appearance of the lung abnormality was not a discrepancy from the original report and thus did not require a telephone call to the ordering physician.
The plaintiff expert radiologist testified that the defendant radiologist breached the standard of care. He testified that the abnormal CT was moderately suspicious for cancer and there should have been a recommendation for follow-up imaging. The plaintiff expert radiologist stated that only recommending general follow-up in the dictation wasn’t sufficient to ensure that the patient received further imaging. He further stated the defendant radiologist should have inquired further into the patient’s clinical history or consulted with the ED physician. He said that had he done so, the defendant radiologist would have learned the patient did not have signs or symptoms of an infection or pneumonia and, thus, there was more likely another disease process involved, including cancer.
Resolution
The case was settled prior to going to trial.
Risk Reduction Strategies
Effective communication of discrepancies and incidental findings is critical in multi-provider environments. These strategies can help:
- Develop a process for managing incidental findings that includes notification and documentation in the patient’s medical record of the recipient, date, time, and follow-up recommendations.
- Consider developing a leveling criterion that clearly defines what is considered high priority requiring direct notification to the ordering physician when an incidental finding is discovered.
- Do not rely on the ordering physician to review the imaging report and discover discrepancies in reports or incidental findings.
- Establish standardized protocols to notify patients and their primary care physicians after discharge of any newly identified findings.
- Conduct regular audits to ensure incidental findings are managed according to policy, and implement improvements where gaps are identified.
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