Chest X-Ray Filed Before Clinician's Review

Cases reprinted with permission from Medical Malpractice Verdicts, Settlements and Experts, Lewis Laska, Editor, (800) 298-6288.

Chest X-Ray Filed Before Clinician’s Review
In anticipation of a cardiac catheterization, a 76-year-old Illinois man underwent a chest x-ray in March 2003. The x-ray showed a 4-cm mass in the left lung, which the radiologist identified as bronchogenic carcinoma.

A staff member in the office of the defendant physician who had ordered the x-ray believed incorrectly that the physician had already seen the results and filed the report in the patient’s chart. The report was not seen again until after a diagnosis of lung cancer had been made in September 2003. By that time, the cancer had metastasized to the man’s liver, pelvis, hip, femur, spine, and shoulder. He died 18 days after the diagnosis was made.

The plaintiff claimed that if the cancer had been diagnosed earlier, the decedent could have been made comfortable during treatment, and he would have survived longer. The defendant admitted liability but argued that the reduction in the decedent’s life expectancy was minimal because his cancer was in an advanced stage in March 2003. The defendant claimed that the net increase in the patient’s pain and suffering was minimal because he would have undergone chemotherapy and radiation if a diagnosis of cancer had been made earlier.

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Outcome
According to a published report, a $1 million verdict was returned.

Comment
This case illustrates just how angry a jury can become when “the system” fails. The plaintiff’s decedent was elderly, with established bronchogenic carcinoma, and the plaintiff did not allege that the six-month delay between the study and diagnosis would have permitted a chance for cure—but only modest improvements in life expectancy and comfort. Nevertheless, the jury returned a substantial ­verdict.

Jurors, like patients, expect study results to be flawlessly communicated to and between clinicians. As clinicians, we must ensure that adequate systems are in place to guarantee that study results are reviewed in a timely manner. I suspect that many of us have received a long-delayed abnormal result and endured the unpleasant experience of contacting the patient to see what shape she or he was in.

Study findings simply cannot be filed until they have been reviewed and acknowledged by a clinician. If this is a problem in your practice, work to establish a system. Any system adopted must assign responsibility for the day-to-day flow of study results to avoid the “pop fly syndrome”—that is, a situation in which everyone thinks someone else is taking responsibility for a study, and the ball is dropped.

A chosen system should also address special circumstances: Miscommunication is known to be more common during holidays, vacations, extended clinician leaves, and use of moonlighters. Consider designating one individual specifically to confirm that abnormal lab results are reported to clinicians, then build two or more additional complementary layers as a “safety net” for the practice. Redundancy can hedge against errors. —DML

Cases reprinted with permission from Medical Malpractice Verdicts, Settlements and Experts, Lewis Laska, Editor, (800) 298-6288.

Chest X-Ray Filed Before Clinician’s Review
In anticipation of a cardiac catheterization, a 76-year-old Illinois man underwent a chest x-ray in March 2003. The x-ray showed a 4-cm mass in the left lung, which the radiologist identified as bronchogenic carcinoma.

A staff member in the office of the defendant physician who had ordered the x-ray believed incorrectly that the physician had already seen the results and filed the report in the patient’s chart. The report was not seen again until after a diagnosis of lung cancer had been made in September 2003. By that time, the cancer had metastasized to the man’s liver, pelvis, hip, femur, spine, and shoulder. He died 18 days after the diagnosis was made.

The plaintiff claimed that if the cancer had been diagnosed earlier, the decedent could have been made comfortable during treatment, and he would have survived longer. The defendant admitted liability but argued that the reduction in the decedent’s life expectancy was minimal because his cancer was in an advanced stage in March 2003. The defendant claimed that the net increase in the patient’s pain and suffering was minimal because he would have undergone chemotherapy and radiation if a diagnosis of cancer had been made earlier.

Continue for outcome >>

Outcome
According to a published report, a $1 million verdict was returned.

Comment
This case illustrates just how angry a jury can become when “the system” fails. The plaintiff’s decedent was elderly, with established bronchogenic carcinoma, and the plaintiff did not allege that the six-month delay between the study and diagnosis would have permitted a chance for cure—but only modest improvements in life expectancy and comfort. Nevertheless, the jury returned a substantial ­verdict.

Jurors, like patients, expect study results to be flawlessly communicated to and between clinicians. As clinicians, we must ensure that adequate systems are in place to guarantee that study results are reviewed in a timely manner. I suspect that many of us have received a long-delayed abnormal result and endured the unpleasant experience of contacting the patient to see what shape she or he was in.

Study findings simply cannot be filed until they have been reviewed and acknowledged by a clinician. If this is a problem in your practice, work to establish a system. Any system adopted must assign responsibility for the day-to-day flow of study results to avoid the “pop fly syndrome”—that is, a situation in which everyone thinks someone else is taking responsibility for a study, and the ball is dropped.

A chosen system should also address special circumstances: Miscommunication is known to be more common during holidays, vacations, extended clinician leaves, and use of moonlighters. Consider designating one individual specifically to confirm that abnormal lab results are reported to clinicians, then build two or more additional complementary layers as a “safety net” for the practice. Redundancy can hedge against errors. —DML

Cases reprinted with permission from Medical Malpractice Verdicts, Settlements and Experts, Lewis Laska, Editor, (800) 298-6288.

Chest X-Ray Filed Before Clinician’s Review
In anticipation of a cardiac catheterization, a 76-year-old Illinois man underwent a chest x-ray in March 2003. The x-ray showed a 4-cm mass in the left lung, which the radiologist identified as bronchogenic carcinoma.

A staff member in the office of the defendant physician who had ordered the x-ray believed incorrectly that the physician had already seen the results and filed the report in the patient’s chart. The report was not seen again until after a diagnosis of lung cancer had been made in September 2003. By that time, the cancer had metastasized to the man’s liver, pelvis, hip, femur, spine, and shoulder. He died 18 days after the diagnosis was made.

The plaintiff claimed that if the cancer had been diagnosed earlier, the decedent could have been made comfortable during treatment, and he would have survived longer. The defendant admitted liability but argued that the reduction in the decedent’s life expectancy was minimal because his cancer was in an advanced stage in March 2003. The defendant claimed that the net increase in the patient’s pain and suffering was minimal because he would have undergone chemotherapy and radiation if a diagnosis of cancer had been made earlier.

Continue for outcome >>

Outcome
According to a published report, a $1 million verdict was returned.

Comment
This case illustrates just how angry a jury can become when “the system” fails. The plaintiff’s decedent was elderly, with established bronchogenic carcinoma, and the plaintiff did not allege that the six-month delay between the study and diagnosis would have permitted a chance for cure—but only modest improvements in life expectancy and comfort. Nevertheless, the jury returned a substantial ­verdict.

Jurors, like patients, expect study results to be flawlessly communicated to and between clinicians. As clinicians, we must ensure that adequate systems are in place to guarantee that study results are reviewed in a timely manner. I suspect that many of us have received a long-delayed abnormal result and endured the unpleasant experience of contacting the patient to see what shape she or he was in.

Study findings simply cannot be filed until they have been reviewed and acknowledged by a clinician. If this is a problem in your practice, work to establish a system. Any system adopted must assign responsibility for the day-to-day flow of study results to avoid the “pop fly syndrome”—that is, a situation in which everyone thinks someone else is taking responsibility for a study, and the ball is dropped.

A chosen system should also address special circumstances: Miscommunication is known to be more common during holidays, vacations, extended clinician leaves, and use of moonlighters. Consider designating one individual specifically to confirm that abnormal lab results are reported to clinicians, then build two or more additional complementary layers as a “safety net” for the practice. Redundancy can hedge against errors. —DML