Index Case 8
Cough
Follow-up
Specialty Consult
Tumor Board
Legal
Review
Documentation
The medical review of this case is somewhat limited. The lawsuit did not stem from any failure of medical workup or treatment. We will focus on two distinct themes that contributed to this bad outcome, and several ways that similar mistakes can be avoided.
First, the physician either did not perform a full review of the chest x-ray, or reviewed it and forgot to document it or discuss it with the patient. Classically, medical students and residents are taught to review the images for themselves. Even without reviewing the images and just having reviewed the radiologist’s interpretation, the necessary information was obvious.
A second issue is the failure of communication. Many malpractice cases involve a failure of communication at some point. Previous cases have shown issues with failure of communication between 2 EM physicians (In Case 5, during which the second physician apparently did not realize the first physician had anticoagulated the patient prior to falling on his way out of the ER). In this case the failure of communication occurred between physician and patient. Any barrier to communication, whether it be language, cultural, stressful work environments, rude behavior from colleagues, or any other number of numerous examples, creates a high-risk situation where bad outcomes become more likely and malpractice lawsuits may arise.
Extensive guidelines exist on management of incidental findings. Many radiologists include these directly in their reports, which is quite helpful for advising patients on necessary follow-up. These incidental findings often seem tangential to a patient’s reason for ED presentation and it can be difficult for a doctor to cognitively switch from a sole focus on searching for emergency conditions to focusing on a new issue that requires outpatient follow-up. This case illustrates the importance of these incidental findings and their appropriate follow-up.
As with every bad outcome, it is worth considering both the individual (considered above) and system issues that contributed to this. A busy ED or urgent care may provide little time for review of records and there may be many interruptions while taking care of patients. One potential way to address this is to have pre-written discharge instructions about incidental findings and advice to follow-up with primary care. Allowing patients access to their own medical records is another way to help prevent this, although this does not abdicate physicians from the responsibility for effective communication (see opennotes.org for an example). Several automated software solutions could be integrated into an EMR as well, including interfaces and workflows that remind the physician at the time of discharge or automatically include incidental finding discharge papers, automatic notification of PCPs, or automated scheduling of follow up imaging with the suggested time frame. Multiple solutions exist that could be implemented.
Bad outcomes such as this one are preventable. Physicians have a responsibility to take care of patients at a high level, and the fact that this lawsuit was dismissed on a legal technicality does not change that fact.