by Laura Hale Brockway, ELS, Assistant Vice President, Marketing, and
Susie Edwards, Risk Management Representative
Presentation
On May 1, 2013, a 69-year-old man came to the emergency department (ED) with worsening shortness of breath.
The patient’s history included smoking, COPD, and an occluded right coronary artery, of which he had a right ventricular infarction. He also had a history of coronary artery bypass graft surgery, myocardial infarction, angioplasty, and stenting multiple times. The patient was taking baby aspirin.
Physician action
Upon admission to the hospital, the patient was seen by a cardiologist. He ordered chest x-rays and noted that there was no evidence of STEMI on the EKG. A CT scan of the patient’s chest taken on May 1 revealed some noncalcified pulmonary nodules.
In documentation for both x-rays, the radiologist recommended either a follow-up PET/CT or a repeat of the CT scan in four to six months to determine the potential for malignancy.
The patient was discharged on May 4, with recommendations to either get a PET or CT scan versus a four-to six-month short-term CT scan. The cardiologist noted that he would try to see whether they could do a PET scan as well.
The cardiologist next saw the patient in his office on August 1. The patient reported shortness of breath and abdominal pain. At this visit, there was no mention of the previous abnormal CT scan. The cardiologist told the patient to return in three months.
The patient was next seen by the cardiologist on November 15, 2013, and February 23, 2014. During these office visits, there was no follow up about the abnormalities from the May 1 CT scan and no follow-up on the recommendations from the radiologist about further testing.
On May 23, 2014, the patient returned to the cardiologist reporting chest pain. A repeat CT scan was done and compared to the CT scan from May 1, 2013. The radiologist reported “multiple, bilateral lung masses; left mass measuring 2.8 x 3.1 cm; malignant process suspected.” A CT-guided biopsy of the lung mass confirmed “small cell neuroendocrine carcinoma, high grade, poorly differentiated.”
The patient went on to receive chemotherapy.
Allegations
A lawsuit was filed against the cardiologist, alleging failure to follow up on the May 1, 2013 CT scan. The suit also alleged that had a follow-up scan been pursued, the patient likely would have been cured.
Legal implications
Cardiologists who reviewed this case for the defense found that the cardiologist’s failure to follow up with the radiologist’s recommendations for further testing was below the standard of care.
Oncologists who reviewed this case found that at the time of the patient’s scan on May 1, 2013, the patient already had advanced cancer and was believed to be incurable. Even if there had been no delay in treatment, his outcome likely would have been the same.
Disposition
A complication for the defense was to have to concede liability on the part of the cardiologist and try to convince a jury that the delay did not change the patient’s treatment or outcome. Because of this difficulty, this case was settled on behalf of the cardiologist.
Risk management considerations
In this case, there was a delay in ordering the follow-up CT scan and/or PET scan as recommended by the radiologist. The need for follow up was noted in two different radiology reports during the patient’s hospitalization. A review of the hospital discharge note would have prompted the cardiologist to order the necessary tests, possibly leading to a timely diagnosis. There was no indication that the discharge summary or hospital notes were reviewed during the follow-up visits, nor a mention of a CT scan or PET scan being ordered.
Ultimately, responsibility for ordering appropriate testing falls upon the treating provider. Implementing a process to ensure the review of the hospital discharge summary, recommendations from other involved specialists, and critical test results during the follow-up visit may have facilitated the continuity of care.
General risk management strategies to assist with follow-up testing include:
- Ask staff members to request the hospital discharge summaries and review any orders and/or recommendations before the patient’s follow-up visit. If needed, staff members could create a note or task in the patient’s chart to remind providers to review. Direct staff members to obtain a copy of pertinent hospital records and labs, tests, and/or radiology reports for the office chart.
- When ordering tests, schedule the follow-up appointment for results review at the time of the office visit with the patient. Use a tracking system to ensure test results are received. Assist the patient with scheduling when needed and ask testing facilities or consultants to contact you if the patient does not come to the appointment. If the patient chooses not to have the test performed, document your discussion with the patient regarding the risks of noncompliance in the medical record.
- Engage patients in their own care and treatment plan by educating them about needed follow-up labs and testing. This encourages them to follow through with the plan to have the test(s) performed. It is important to document these conversations and any education in the progress notes.
Laura Hale Brockway can be reached at laura-brockway@tmlt.org
Susie Edwards can be reached at susie-edwards@tmlt.org.
