Malpractice Case: How Careful Physicians Can Miss Vital Information

Gordon T. Ownby


December 05, 2018

Medscape Editor's Key Points:

  • When receiving test results from other clinicians, be sure to review each line to avoid overlooking details.

  • Place all reports and addenda in a patient's chart to maintain an ongoing record of care and to avoid missed details or communication.

  • If you spot an oversight, immediately notify the patient and get details from other physicians involved.

Get the Whole Story From a Patient's Report

Communicating critical test results is often done at multiple levels. But sometimes one or more channels will break down and expected redundancies will evaporate. All of this makes it vital that the treating physician considers every single line of the report that does make it through.

A middle-aged woman went to her gynecologist, Dr. G, for her annual well-woman exam. She told Dr. G of increased stress in her life, fatigue, and problems with her hormone patches. Though a breast exam showed no masses or discharge, Dr. G prescribed a mammogram per her custom and practice. She also adjusted the patient's hormone replacement therapy. Several months went by until, it appears, the patient noticed a lump and then went in for the mammogram 3 days later.

The mammogram showed a 2.0-cm mass in the deep upper outer quadrant of the right breast, corresponding with the patient's report. An ultrasound performed at the same visit showed "two solid masses" at 8' and 9 o'clock, measuring 1.7 x 1.4 x 1.1 cm and 0.9 x 0.8 x 0.9 cm.

The radiologist recommended an ultrasound-guided biopsy, which Dr. G authorized. The radiologist performing the biopsy, Dr. R, noted in his report that he took two specimens and that he would create an addendum once the pathology report became available.

Six days after the procedure, Dr. G saw the patient for vaginal irritation and to go over the breast biopsy results. Because Dr. G had not yet learned the results, she had her office follow up with the medical center and told the patient she would call as soon as she had the biopsy results. The next day, she received a faxed report from the pathologist, Dr. P.

At the top of page 2 (which may have been faxed first), under a heading of "Diagnosis:" the report stated: "Inflammation. Changes suggestive of Ruptured Cyst." Dr. G initialed page 2 of the report in a blank area next to the stain results for both specimens. She did not notice what Dr. P included in his interpretation for Specimen A: "Findings of immunoperoxidase stains support the morphologic findings of invasive ductal carcinoma."

Specimen B was "negative for malignancy." Invasive ductal carcinoma was also included in Dr. P's synoptic report on page 1, and the reference to an inflamed ruptured cyst at the top of page 2 actually was a continuation of the description of Specimen B from page 1.

On her instructions, Dr. G's office called the patient and reported the findings of the ruptured cyst.

That same day, Dr. R dictated an addendum to his biopsy report, noting: "I suggest appropriate surgical/oncology consultation regarding excision and further management for the invasive carcinoma." Dr. R charted no communication plans, and Dr. G's chart did not contain a copy of Dr. R's report.

The patient visited Dr. G again just over 3 months later, complaining of pelvic pressure and back pain. At the end of the visit, the patient asked Dr. G to look at the biopsy site, wondering if a mass there was a hematoma.

After looking at the mass, Dr. G told the patient it was not a hematoma and instructed her to see a breast surgeon as soon as possible. Dr. G sent the records to a surgeon, but the patient called back to ask that the records be sent to another surgeon who had previously done a breast reduction on her. Dr. G charted: "I reviewed the records prior to transfer and discovered that her November biopsy indicated a breast malignancy which was not conveyed to the patient in November." Dr. G phoned the patient to discuss the results and to confirm her visit to the surgeon. She also called the surgeon to provide a timeline.

New tests revealed a 4.3-cm irregular-shaped mass in the right breast and pathologic-appearing nodes in the right axilla. Dr. G and the patient resolved a subsequent lawsuit informally.

In cases involving missed communications, there is often more than one point at which a straying course of events can be corrected. Accept that as your challenge.

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 article was originally titled "When Information Hides in Plain Sight."


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