Allegation
Patient’s family alleged that the radiologist failed to communicate abnormal post procedure chest x-ray results to the ordering interventional radiologist.
Case Details
A 50 YOM with a history of emphysema on home oxygen was admitted to the hospital for a CT guided lung biopsy of a mass found on a previous x-ray. The procedure was performed by an interventional radiologist (IR) and concluded approximately one hour later. A CT scan of the lungs was performed immediately following the procedure. The procedure note indicated that the patient developed a small amount of hemorrhage in the pulmonary parenchyma and no pneumothorax. The IR physician ordered a chest x-ray to be done two hours after the procedure.
The patient was admitted to the recovery area with nasal cannula at 6 liters per minute of oxygen. Ten minutes after the patient was admitted, the patient’s blood pressure dropped but self-recovered within 30 minutes. Two hours after admission, the recovery room nurse called the IR physician to report the patient’s decompensating clinical condition including labored respirations, pulmonary congestion, diminished breath sounds, and drop in pulse oximetry with 15 liters per minute of oxygen. The nurse also conveyed the results of the follow up chest x-ray which included a moderate left pneumothorax with extensive pulmonary hemorrhage. An order for a nebulizer treatment was given.
An hour later, the nurse called the IR physician to notify him of continued clinical deterioration. The IR physician ordered another chest x-ray and to “just wait.” The patient’s clinical condition continued to decline, and minutes later the nurse called back to report that the patient was in respiratory failure. The nurse asked for the IR physician to assess the patient at the bedside. Minutes after communicating with the IR physician the patient respiratory arrested, and emergency resuscitative efforts were undertaken which included intubation and an emergent placement of a chest tube.
The patient remained intubated and was transported to the intensive care unit. Later in the day, the patient arrested again and was resuscitated. The patient remained unresponsive, and the family decided to provide comfort measures only. The following day, the patient expired.
The family filed a lawsuit against the radiologist who read the post-procedure x-ray claiming he failed to communicate the critical results to the IR physician.
Expert Testimony
The defense expert was an interventional radiologist who was consulted to review the care provided by the radiologist. He testified that the care provided by the radiologist was appropriate and met radiology standards. The radiologist read the film and notified the bedside nurse of the patient’s deleterious condition after the biopsy. Evidence was found that the attending IR physician was notified of the chest x-ray results and that he had ordered an additional chest film 2 hours after it was reported that the patient was in distress. The expert opined that the IR physician had an obligation to treat the patient when he developed a pneumothorax and started to decompensate.
Additional evidence was found from the hospital’s picture archiving and communication system demonstrating that the interventional radiologist viewed the chest x-ray results and was aware of the findings.
Resolution
The radiologist successfully defended his care by providing documentation that the critical results were communicated to the healthcare team. There was additional documentation provided by the hospital’s audit trail from the metadata of the picture archiving and communication system. The plaintiff could not demonstrate that the radiologist contributed to the patient’s death and voluntarily dismissed the radiologist prior to trial.
Risk Reduction Strategies
Develop a process for handling critical or urgent findings. Ensure that the radiology department has a process to timely communicate critical information from radiological exams and provide documentation within the medical record that the results were communicated to the ordering physician. Do not rely on other members of the healthcare team to document results or communicate results to the ordering physician.
When critical or urgent results are found, consider the following:
- Notify the ordering physician and document your discussion within the medical record.
- Ensure that computerized radiology records capture an accurate time stamp of when films are taken and reviewed by radiologists.
- Do not ignore clinical deterioration. Review clinical data with the referring physician to avoid a delay in responding to a critical result.
- Review documentation for accuracy and completeness.
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