Case 3

This case demonstrates the following errors in critical test value reporting:

·         failure of radiology staff to report the value to the ordering physician

·         failure of ED physician to communicate the result to the patient or his PCP

Claim/Lawsuit Allegations

Claimant alleges that all defendants failed to diagnose and inform him of a pelvic fracture, based on x-ray findings; that this failure resulted in a 7-month delay in getting treatment and much more extensive reconstructive surgery.

Co-Defendants were the Hospital, ED Physician, Primary Care Physician, Radiologist, and Physician Assistant (in ED), later dismissed.

Case Summary

The patient, a 58 year old man, was brought by ambulance to the ED of his local hospital after he had fallen out of his car and one of the tires rolled over his upper thighs.  He complained of severe pain in his pelvic area and legs.

The patient was examined by a Physician Assistant (PA), who ordered X-rays of LS spine, pelvis, left hip and right lower leg.  There was no radiologist present in the hospital at that time. (after 5 pm), so the PA looked at the films.  She noted her impression: all the films appeared negative except for pelvic region, which indicated pubic symphysis dyasthesis.  She did not request an orthopedic consult or inform patient that a preliminary reading (before radiologist) of his x-rays showed a possible fracture of his pelvic bone.  When she saw him, the patient was able to stand.

(Although it wasn’t established by the documentation, the PA testified that it would have been her practice to tell the ED physician what her impression was after reviewing films, and that she also would have shown the films to the ED physician.)

The PA turned the patient’s care over to the ED Physician when her shift ended at 11pm.

While in the ED most of the night, the patient received various pain medications.  At 5am the next morning, the ED physician examined the patient, and concluded that he was pain-free and able to walk, and then discharged the patient to home.  The patient was given instructions for contusion care, a prescription for pain medicine, and to follow-up with his PCP that day.  The record did not reflect that the ED physician either informed the patient that he might have a fracture or referred the patient to an orthopedist.  

In the afternoon of the same day, the radiologist read the patient’s pelvic x-ray as showing diastasis and minimal subluxation of symphysis pubis, with clinical correlation recommended. All other films were read as negative for fracture.  Again, there was no documentation that this final reading was reported to that day’s ED physician.  Testimony revealed that the radiologist had issued a written report but, because he didn’t follow the hospital’s Radiology/ED “Follow-up Protocol” and complete the follow-up form correctly, the clerical staff in the ED was not alerted to call the patient with this diagnosis.

5 months later: The patient went to an orthopedist due to continuing pain.  This physician ordered new x-rays and he diagnosed multiple pelvic fractures, dating from the initial accident, and disruption of the pelvic ring.  This doctor informed the patient about the fractures and referred him to an orthopedic surgeon.  2 months later: The patient had reconstructive surgery to restore integrity of the pelvis.  It was the surgeon’s opinion that the procedure that was necessary after the 7-month delay was much more extensive than it would have been had the diagnosis been made immediately and the patient advised to seek further medical care.

Ultimately, the patient had an excellent result from the surgical repair.  Currently he seems to be functioning well, with almost no residual disability, although he complains of constant back pain.

Case Outcome

The lawsuit was settled prior to trial, on behalf of the ED Physician, Radiologist and Hospital.  The claim was dismissed without payment, as to the Primary Care Physician.  

Risk Issues

• As noted above, the patient had been discharged several hours before the radiologist looked at the films.  However, the Hospital and its ED failed to notify the patient and/or his PCP of the abnormal x-ray findings, once the report of the final reading (showing fracture) was issued. 

• Even though the hospital had a policy and procedure for patient notification of test results, there seemed to be misunderstanding among the physicians (both Radiology and ED) about who had what responsibilities under it. By not complying with its own policy, the hospital put itself at risk for a claim of breach.  Policies need to be clear as to responsibility.

• The radiologist issued a written report of his interpretation of the patient’s films. There was, however, an error in the way he filled out a hospital form that went with his official report.  Due to this error, the clerical staff in the ED were not alerted to make the follow-up contact with the patient, in accordance with the hospital policy.  

• The radiologist failed to notify the ED physician on duty at the time he made his x-ray interpretation, although he knew or should have known that his diagnosis of fracture in the pelvic region was significant.