by Gracie Awalt, Marketing Associate, and
Roxanna Maiberger, Risk Management Representative
Presentation
On May 16, a 40-year-old man came to his family physician reporting left shoulder pain for two weeks. The physician ordered an MRI and administered an injection of methylprednisolone and lidocaine.
Physician action
On June 14, an MRI was performed on the patient’s left shoulder. Ten days later, the patient returned to the family physician with pain in multiple joints and bones in his lower back. After receiving another injection of methylprednisolone and lidocaine, the patient asked to see his MRI results. The physician said she would contact the imaging center for the results. The physician did not contact the center until the patient was seen again on November 4.
Between the June and November visits with the family physician, the patient saw a chiropractor to manage back pain. During this time, the patient’s self-rated pain level was mild to moderate, with the highest pain level being a 5 out of 10.
At the November 4 appointment, the patient reported a scalp lesion and pain in multiple bones and joints. Additional imaging tests were ordered. Upon receiving this new set of orders, the medical diagnostic imaging center discovered that the MRI results from June 14 had not been read or reported.
A radiologist read the MRI report from June and noted the patient had bone marrow abnormalities consistent with many diagnoses, including sub-acromial and sub-deltoid bursitis, and marrow signal abnormalities involving the coracoids and glenoid process. The radiologist attributed these issues to possible metastatic tissue disorder, vasculitis, metastatic disease, or osteomyelitis. These findings were communicated to the family physician on November 4.
On November 6, the patient was diagnosed with widespread metastatic angiosarcoma after the latest left shoulder MRI showed metastatic disease replacing the coracoid process and glenoid, which had grown since June. The family physician’s impression was that the marrow space signal progressed to involve the distal scapula, suggesting metastatic disease. Another MRI showed lesions within the scapula, ribs, and proximal left humerus.
On November 9, a CT of the abdomen indicated widespread bony metastatic disease, encroaching on the spinal canal, and multiple liver lesions. On November 13, a PET/CT scan of the patient’s skull base showed a left adnexal mass that could have been the primary tumor site.
A scalp lesion biopsy on November 18 showed an angiosarcoma. It was unclear if this was the primary tumor site. After seeing an oncologist on November 10, the patient received chemotherapy via subcutaneous port and radiation.
On February 13, the patient’s condition worsened, with an MRI revealing diffuse metastatic disease in the patient’s lumbar spine, sacrum, and iliacs. Compression deformities of L4-5 were noted, as well as a fracture of the L3 vertebral body with bony retropulsion that compromised the central spinal canal. The L3 was cemented to stabilize the collapsed vertebrae.
The patient died from angiosarcoma on October 16, more than 18 months from the first visit with the family physician. The primary origin of the cancer remains unknown.
Allegations
A lawsuit was filed against the family physician and the imaging center. Allegations included failure to interpret the initial MRI results in a timely manner (the imaging center) and failure to follow up on the MRI results (the family physician). It was alleged that these failures resulted in the patient experiencing greater pain and reducing the patient’s life expectancy.
Legal implications
Most of the consultants contacted by TMLT to review this case agreed that failing to follow up on the June MRI results fell below the standard of care. However, the consultants were not in agreement on whether the patient’s outcome would have been changed or avoided if treatment had been initiated earlier.
Most of the consultants agreed that the patient’s cancer was rare, aggressive, and advanced upon presentation. However, one consultant believed earlier chemotherapy could have improved the patient’s longevity.
Two of the plaintiff’s experts agreed that both the family physician and the imaging center were responsible for following up on the initial MRI results. The radiologist should have interpreted and communicated the results to the physician, and the physician should have contacted the radiologist to ask about the delayed results.
One plaintiff’s expert criticized the imaging center for having poor policies and procedures and suggested implementing redundant procedures for reviewing results as a backup plan. Another expert noted that an earlier diagnosis may have helped the patient respond better to earlier chemotherapy, slowed tumor development, and reduced the patient’s pain.
A consultant for the defense supported the care provided by the imaging center. This consultant stated that “the standard of care requires reasonable care, not perfection,” and noted that the radiologist traditionally followed a reliable review procedure. Further, this consultant noted that unintentional delays do happen, and that the physician or patient should have called to follow up.
Disposition
This case was settled on behalf of the family physician and the imaging center.
Risk management considerations
Tracking and follow up with lab/diagnostic imaging is consistently among TMLT’s top ten risk management considerations.1 Having a reliable tracking and follow-up policy is prudent, and it is critical that these protocols are followed by all staff members. Additionally, these policies should be reviewed at least annually to reevaluate and adjust them as needed to ensure an accurate reflection of the protocols being followed.
Additionally, The American College of Radiology (ACR) states, “communication of information is only as effective as the system that conveys the information. There is a reciprocal duty of information exchange. The referring physician or other relevant health care provider also shares in the responsibility for obtaining results of imaging studies ordered and acting on them in an appropriate manner. Formulating an imaging interpretation requires the commitment and cooperation of administrators, referring physicians, interpreting physicians, and other health care providers.” 2
ACR also provides guidance on emergent or “nonroutine” communications by indicating that, “in emergent or other nonroutine clinical situations, the interpreting physician should expedite the delivery of a diagnostic imaging report (preliminary or final) in a manner that reasonably ensures timely receipt of the findings. This communication will usually be to the referring physician/health care provider or their designee. When the referring physician/health care provider cannot be contacted expeditiously, it may be appropriate to convey results directly to the patient, depending upon the nature of the imaging findings.” 2
The interpreting and referring providers should have policies and procedures in place for emergent/nonroutine clinical scenarios that include appropriate documentation of these communications.
When policies are reviewed and/or changed, all staff members should acknowledge the change by signing and dating the policy. Creation and accountability of these policies can help mitigate lab/diagnostic imaging orders being missed and ultimately reduce chances of delays in diagnosis. Consult your medical liability provider to see what sample policies, documents, and other resources are available (e.g. CME courses) on this topic.
Generally, an electronic health record (EHR) system will have a lab/diagnostic imaging functionality included, so it is recommended to consult your EHR vendor to ensure this is being effectively used. If an EHR system is not being used, establish a tracking log for labs and other diagnostic imaging orders that can be checked regularly. The log allows for appropriate follow up for pending orders.
Document consultations with patients or imaging centers regarding completed or pending lab orders. If a patient does not complete the ordered labs/diagnostic imaging orders, it is also important to document your efforts to encourage compliance.
From a risk management perspective, it is critical that any practice or health care entity that handles incoming and outgoing lab/diagnostic imaging orders create, implement, and maintain tracking policies and procedures.
Source
1. Viner L. 2018 risk management trends analysis. TMLT Resource Hub. September 24, 2019. Texas Medical Liability Trust website. Available at https://hub.tmlt.org/risk-management/2018-risk-management-trends-analysis. Accessed October 15, 2020.
2. American College of Radiology. ACR Practice Parameter for Communication of Diagnostic Imaging Findings. Available at https://www.acr.org/-/media/ACR/Files/Practice-Parameters/CommunicationDiag.pdf. Accessed October 26, 2020.
Gracie Awalt can be reached at gracie-awalt@tmlt.org.
Roxanna Maiberger can be reached at roxanna-maiberger@tmlt.org.
