Presentation
A 77-year-old woman with a history of cigarette smoking and COPD came to her family physician reporting a lump in her right breast.
Physician action
The family physician ordered a diagnostic mammogram, and the patient went to a local hospital for the test. The results of the mammogram were normal, so the radiology technician requested an ultrasound. The order was obtained from the family physician’s group.
The ultrasound revealed a complex mass suspicious for a neoplastic process. A chest CT was suggested for further evaluation.
The radiology reports for the mammogram and the ultrasound were sent to the physician’s group practice, where an employee filed them in the electronic health record (EHR). The family physician reviewed the mammogram results, but was unaware that an ultrasound had been completed. He did not see the ultrasound report.
One week later, the patient returned for a follow-up visit related to her COPD. There was no discussion of the breast lump or the recent testing.
The patient continued to see the family physician over the next year for her COPD and other chronic health issues. There was no mention of the breast mass or of a breast examination. Eighteen months after the mammogram and ultrasound, the family physician ordered another screening mammogram. The test revealed the mass and it was discovered that the mass had been identified in previous testing. The diagnosis was breast cancer with possible metastasis to the lungs.
Two weeks later, the patient was hospitalized for shortness of breath. She was noted to have advanced COPD, bipolar disorder, hypertension, diabetes, prior colonic perforation, GI bleed, and thrombocytopenia. An oncologist evaluated the patient, but the patient and her family “made a decision not to have any intervention done.” She was discharged to hospice and died within three weeks of her diagnosis.
Allegations
A lawsuit was filed against the family physician and his group, alleging failure to timely diagnose breast cancer.
Legal implications
Physicians who reviewed this case for the defense were critical of the oversight regarding the ultrasound report. It was argued that since the patient had a palpable lump with a normal mammogram, the family physician should have requested additional studies rather than being satisfied with the mammogram results. The family physician had multiple subsequent patient visits that presented opportunities to review the medical records and discover that the ultrasound findings had been missed.
There was disagreement between the family physician and the group about the proper procedures for reviewing test results. The group’s administrator believed the system in place was adequate and that the family physician should have discovered the ultrasound report when he received and reviewed the mammogram report.
The family physician did not like to use the EHR and relied on staff members to alert him to positive test results. In this case, a staff member indexed the reports to the family physician’s EHR dashboard, but did not notify him directly.
Causation was also an issue in this case. An oncologist who reviewed this case stated that the patient’s co-morbidities were dramatic and that her quality of life was poor. It was likely that the cancer diagnosis did not affect the outcome and that COPD was the cause of death.
Disposition
This case was settled on behalf of the family physician and his group. The lapse in communication regarding the test results led to the decision to settle this case.
Risk management considerations
It is clear that the family physician was not reviewing the entire record; therefore, treatment decisions were based on the presenting symptoms with minimal attention given to the patient’s history. Reviewing notes from previous visits or maintaining an updated problem list can help physicians deliver timely patient care.
Each health care professional needs to have a system in place to ensure that abnormal findings that require further studies or referrals are reviewed and acted upon. In this case, the physician relied on staff members to alert him to positive test results, but this process was not commonly accepted in the group.
Develop and follow a written policy regarding follow-up on test results. A written policy establishes how test results are handled and eliminates misunderstandings of responsibility or process. When implemented, the policy should be dated and signed by the physician, indicating authorization of the policy. The date should then be updated each time the policy is revised or reviewed. All staff members should sign and date their acknowledgement and understanding of the policy.
