Malpractice: When Small Oversights Lead to Major Errors

Gordon T. Ownby 


July 03, 2018

Medscape Editor's Key Points

  • In large medical groups, where numerous physicians may treat the same patient, extra care must be taken to correctly identify patients and their records.

  • Complex systems and processes, which are often necessary for large groups, may also create unintended risks.

  • In the following case, there are several points where identity errors could have been caught; physicians need to stay alert and double-check to prevent mistakes that could lead to unnecessary surgery.

The Case

One of the risks in the care given at large medical groups is that many physicians may treat a single patient. Another risk is the complexity of the systems involved and how much trust physicians must place in those systems.

Factor in an error made by an outsider, and the chance of injury increases.

Sara Tompkins (not her real name) was a 43-year-old patient of Dr IM, an internist at a large, multispecialty medical group. On June 23, Dr IM received a telephone message that Ms Tompkins reported getting "food poisoning on June 22 in Las Vegas." The next day, Ms Tompkins executed an authorization for the Las Vegas hospital to release all medical records, "including x-rays," to the medical group where Dr IM practiced.

The records from the Las Vegas hospital revealed a sudden onset of nausea, vomiting, and diarrhea. Though records revealed that an x-ray was taken and that gastroenteritis was diagnosed, no copy of the films or of the radiographic report was included in the transmittal. After several further attempts by Dr IM's medical group to obtain the films, the Las Vegas hospital finally sent copies of the films and of the report to Dr IM in November. Because Dr IM does not read films, she filled out a "radiographic request form" containing Ms Tompkins' name and age and sent the unopened envelope to the medical group's radiology department.

Three days later, Dr R, a radiologist at the medical group, reviewed films of Sara Tompkins dated May 29 of the same year. Dr R's impression was a "contracted, stone-filled gallbladder." The next week, Dr IM examined Ms Tompkins and advised her that the film from the Las Vegas hospital revealed that she had gallstones. Dr IM referred the patient to the group's general surgery department for a possible cholecystectomy and noted that the patient "does complain of recurrent epigastric discomfort over time, but is otherwise feeling well."

Three weeks later, the patient was examined by a general surgeon at the medical group, who recommended surgery for his diagnosis of chronic calculous cholecystitis. The surgeon performed a laparoscopic cholecystectomy. The pathology report revealed cholecystitis but no stones. It was only after surgery that the group discovered that the films sent from the Las Vegas hospital were for another Sara Tompkins, who was 16 years younger than Dr IM's patient.

The patient sued Dr IM, Dr R, the general surgeon, the assistant surgeon, and the medical group itself for failing to note the difference in the date of birth between the two "Sara Tompkins." The plaintiff's theory against Dr IM was that she should have questioned the situation given the incompatibility between the radiologist's report of a contracted, stone-filled gallbladder and her own clinical findings.

As it turned out, the patient's attorney dismissed all of the individual physicians and elected to proceed against the medical group alone. The defense of that group was complicated by the group's loss of several significant medical records. At arbitration, the patient won an award of nearly $600,000 for the unnecessary loss of her gallbladder.

Any physician casually reviewing the facts of the case can easily spot all of the points at which the identify error should have been caught.

The challenge to physicians practicing in large group settings is to stay alert to the kinds of errors that his or her colleagues may have missed.

This case comes from Medicine on Trial, originally published by Cooperative of American Physicians, Inc., to provide risk management lessons from litigated case histories. The original title was "It's Always Okay to Verify the Patient's Age."


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