by Laura Hale Brockway, ELS, Vice President, Marketing, and
Tamara Vasquez, Risk Management Representative
Presentation
A 31-year-old woman came to a stand-alone emergency center reporting excruciating shoulder and neck pain. The pain started on the right side of the neck and radiated to her shoulder and base of her skull. The patient reported that the pain increased rapidly and became severe, followed by numbness and tingling in her arms, legs, and the right side of her body.
Physician action
At 12:14 a.m., Emergency Medicine (EM) Physician A ordered a CT scan of the brain and cervical spine. Radiologist A reported that there were no significant abnormalities seen.
The patient was transferred to Hospital A at 4:12 a.m. with a diagnosis of rhabdomyolysis, abnormal creatinine clearance, and Hepatitis B. She was treated by EM Physician B and Hospitalist A. An MRI of the cervical spine was performed at 7:03 p.m. and the results reported by Radiologist B at 11:52 p.m. The report described an epidural mass measuring 8 mm in greatest depth at C4 and 7.5 mm at C3. The lesion extended from C2 to C7 and there was moderate to severe cord compression.
The patient was transferred by air ambulance to Hospital B for a C3-5 laminectomy and decompression with epidural hematoma washout. The surgery was performed at 8:50 a.m. The clot was sent to pathology, where it was later confirmed to be a blood clot.
The day after the surgery, an arteriogram showed no vascular malformations or pathologic lesions. An MRI with and without contrast showed resolution of the epidural hematoma.
Over the next several days, the patient began to have sensation in her legs and had increasing strength in her arms. She was alert and had normal speech.
The patient was transferred to an inpatient rehab facility where she spent three-to-five hours per day, five days per week in intensive physical and occupational therapy. She was diagnosed with neurogenic bladder and bowel. Her condition was listed as “good. Weak but improving upper extremities; plegic in lower extremities.” There were no documented cognitive defects.
One month later, the patient was discharged from inpatient rehab with a power wheelchair. An MRI of the cervical spine, taken six months after discharge, showed regional myelomalacia from C3 to C6 and posterior annular tears at C4-5 and C5-6. She continues to receive physical and occupational therapy.
Allegations
A lawsuit was filed against Radiologist A. The allegations were failure to properly interpret the CT scan and failure to diagnose the epidural mass. This led to a delay in further testing, diagnosis, and treatment. The stand-alone emergency center, Hospital A, EM Physician B, and Hospitalist A were also named in the lawsuit.
Legal implications
The plaintiff’s radiology expert stated that Radiologist A misinterpreted the CT scan results, and that it did show a hyperdense right posterolateral epidural mass compressing the spinal cord measuring 6 mm in depth and 17 mm transversely. An MRI showing this mass was performed 18 hours later.
Defense radiology consultants conducted blind reviews of the CT scan. All but one of the reviewers described seeing the mass in the film. Yet, many of these reviewers expressed support for Radiologist A. It was their opinion that when a CT scan is ordered and the only indication is “neck, shoulder, and back pain”, it is unreasonable for a diagnostic radiologist to suspect such a rare occurrence as a spontaneous epidural hematoma.
Several of the radiologists reviewing this case also pointed out that an MRI was the appropriate study for soft tissue imaging, not CT.
Another issue in the case was the delay in the patient’s treatment at Hospital A. She arrived with full motor function at Hospital A at 4:12 a.m. At 10:45 a.m., she was unable to move her right arm and leg and had issues with urinary retention. The MRI was not performed until 7:03 p.m. and the tele-neurology consult did not occur until 11 p.m. Many of the experts who reviewed this case said the time lost at Hospital A likely worsened the patient’s symptoms.
Disposition
This case was settled on behalf of Radiologist A. EM Physician B, Hospitalist A, and Hospital A also settled their case with the plaintiff.
Risk management considerations
Although it can occur in any medical setting, radiologists interpreting tests for an emergency center or hospital Emergency Department make up nearly half of all radiology malpractice calims, with diagnostic errors being the primary source of liability risk. 1, 2
Causative factors in an ED can include time constraints associated with the emergent nature of a patient’s symptoms, inadequate information about a patient’s medical history or condition, and heavy patient caseloads.
Among the allegations against Radiologist A was the failure to properly interpret the CT scan. As a result, the patient’s symptoms worsened and there was a delay in moving the patient to a higher-level facility. It was also noted that an MRI was not done for 15 hours after the patient was transported to Hospital A, and that Radiologist B did not read the results for an additional five hours. As several consultants pointed out, ordering an MRI study may have led to a more timely diagnosis and more urgent care for the patient.
Additional contributing factors in radiology liability include:
- inadequate clinical history — not knowing a patient’s history or the context for which the imaging was ordered can lead to procedural errors or complications such as performing the wrong kind of imaging study;
- communication errors — either results not being communicated to an ordering provider or to the patient, or not communicating in an appropriate or timely manner;
- documentation errors — limited detail, burying of critical information, failure to note limitation of study, and lack of follow-up recommendation when needed . 3
Sources
- Robinson JD. et al. Emergency radiology: An underappreciated source of liability risk. Journal of the American College of Radiology. Volume 17, Issue 1, 42-45. January 2020. Available at https://www.jacr.org/article/S1546-1440(19)30975-5/fulltext. Accessed October 9, 2024
- Walter M. High percentage of radiology malpractice claims originate in emergency department. Radiology Business. Innovate Healthcare. August 28, 2019. Available at https://radiologybusiness.com/topics/care-delivery/healthcare-quality/radiology-malpractice-claims-emergency-imaging. Accessed October 9, 2024.
- Hille A. Top 5 unique risks for radiologists. Ultra Risk Advisors. Available at https://ultrariskadvisors.com/top-5-unique-risks-radiologists/. Accessed October 9, 2024.
Laura Brockway can be reached at laura-brockway@tmlt.org.
