Failure to communicate mri results

Case Closed

a case study to help you manage risk.

presentation

A 56-year-old woman came to a pain management specialist in July 2007 for treatment of back pain. The patient had a history of chronic obstructive pulmonary disease.

presentation

In August 2007, the pain management specialist ordered an MRI of the thoracic spine. In addition to some spinal pathology, the radiologist noted a “possible 9 mm right lung nodule.” The radiologist recommended a CT scan if clinically warranted.

presentation

The patient’s next appointment was delayed due to bad weather and scheduling conflicts. She next saw the pain management specialist in October 2007. There was no mention of the pulmonary nodule.

The patient had two more office visits that year and 14 office visits in 2008. The patient saw either the pain management specialist or his advanced practice registered nurse (APRN).

presentation

In July 2009, the APRN reviewed the chart and noticed the MRI report. She discussed the MRI results with the patient and told her to discuss them with her primary care physician. The radiology report was faxed to the patient’s primary care physician.

presentation

The patient’s primary care physician ordered a CT scan, which revealed a right paratracheal mass. The mass was biopsied and found to be a small cell carcinoma. The patient was treated with chemotherapy and radiation.

presentation

By March 2010, she was in remission, but her COPD worsened. She was hospitalized several times in 2010 with weakness, chest pain, and difficulty breathing.

presentation

The patient was found dead at her home on April 14, 2011. The cause of death was listed as multi-system organ failure. Lung cancer was listed as a contributing factor.

allegations

A lawsuit was filed against the pain management specialist, alleging delay in diagnosing the patient’s lung cancer. The plaintiffs claimed the delay reduced the patient’s prognosis for survival and ultimately caused her death.

legal implications

Although the lung nodule was an incidental finding on the MRI, it was difficult to argue that the pain management specialist did not have a duty to act on the findings by:• discussing them with the patient, • sending them to her primary care physician, and/or • ordering the CT scan.

The pain management specialist testified that he should have notified the patient.

legal implications

Defense experts who reviewed this case agreed. However, defense oncology experts argued that the “late” diagnosis did not affect the patient’s prognosis and did not cause her death. The prognosis for small cell lung cancer is poor, regardless of the timing of the diagnosis.

This cancer responds well to the initial round of treatment, as in this case, but it typically recurs and causes death within another year. Defense experts argued the patient was in remission and likely died due to an exacerbation of her COPD.

legal implications

Despite the strong causation defense, the failure of the pain management specialist to act on the MRI results was difficult to overcome. This case was settled on behalf of the pain management specialist.

disposition

The following processes can help address the potential for an allegation of delay in diagnosis and treatment.

• Develop a tracking system for all labs, diagnostic studies, and referrals. This can be done through a paper log or through the electronic medical record.

• Initial and date all laboratory and diagnostic reports upon your review of the report. If hard copy reports are reviewed, make sure documents are not filed before your review.

risk management considerations

(continued)• Document follow-up actions, if abnormal results are

noted on the laboratory/diagnostic report.• Document the discussion with the patient about

diagnostic abnormalities. Each attempt made by a staff member to contact the patient with follow-up instructions should be documented.

• Consider a referral to a specialist for questionable diagnoses.

• Establishing these processes can maximize a physician’s defensibility and prevent a delay in diagnosis and treatment for the patient.

risk management considerations

disclaimer

This closed claim is based on an actual malpractice claim from Texas Medical Liability Trust. This case illustrates how action or inaction on the part of the physician(s) led to allegations of professional liability, and how risk management techniques may have either prevented the outcome or increased the physician’s defensibility. This study has been modified to protect the privacy of the physician and the patient.© Copyright 2016 TMLT.

about tmlt

With more than 19,000 health care professionals in its care, Texas Medical Liability Trust (TMLT) provides malpractice insurance and related products to physicians. Our purpose is to make a positive impact on the quality of health care for patients by educating, protecting, and defending physicians. www.tmlt.org

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