The patient’s children sued the ED physician, radiologist, and PCP, alleging failure to identify and follow up on a lung nodule, resulting in the patient’s death from lung cancer.

The case was settled in the high range (> $500,000)

Clinical Perspective

1. Although each service operated strictly within the expectations of its domain, the PCP was unaware of an important incidental finding. Neither the radiology nor emergency departments had reliable processes to ensure communication of this finding to either the PCP or the patient.
   Establishing protocols for who is responsible for ensuring the communication of an incidental X-ray finding to the appropriate physician for follow up can avoid the problem of “no one” being responsible. Independent services need to collaborate to clarify responsibility, set clear expectations, and develop reliable and verifiable processes to assure that worrisome test results are brought to the attention of the PCP. Validation that they have been received by the PCP (or covering physician) is a critical step to ensure that results have been received and seen by the appropriate parties. Designated staff may be assigned to manage the process, thereby reducing physician workload while ensuring completion of the process and minimizing risk.

Patient Perspective

1. This patient presented to multiple providers, including his primary care provider, with back and shoulder pain. From his perspective, he was acting appropriately, both in seeking emergency care and following up with his PCP at the right intervals. He expected that all information obtained in the ED would be available and reviewed by the primary care physician as part of his examination. His family contended that the PCP’s failure to obtain and review the findings resulted in a delay in his diagnosis and treatment—and potentially reduced his life expectancy.
   Most patients are unaware of the complexities of ensuring that diagnostic tests reach the appropriate provider, and—not unreasonably— expect that the clinician will review the relevant information prior to determining a treatment plan. From the patient perspective, all relevant information should be readily available to the treating provider and it is the responsibility of the treating physician to have the appropriate information at the time of the visit. Development of both hospital and office-based processes are necessary to ensure that this expectation can be met.

Risk Management Perspective

1. Lack of a process to ensure provider review of all incoming test results and review of this patient’s chart in the office created several missed opportunities for earlier diagnosis and treatment of this cancer.
   PCPs are responsible for overseeing their office-based processes. They need to be involved in the development and oversight of test result management systems within their office practice in order to assure that they view all relevant test results without fail. Physicians cannot act on abnormal results that they don’t see. The presence of a radiology report in the patient’s chart that was filed without the PCP’s review indicates a failure in the test result management process.

Legal Defense Perspective

1. Expert reviewers for the defense could not support the physician’s documentation practices nor his admittedly inconsistent practice of reviewing the record prior to the visit.
   Review of previous notes and test results prior to the patient’s visit is essential to making a full patient assessment and timely diagnosis. Documentation should always include clinical rational for decision-making and a prescribed treatment plan. Scant documentation of a patient’s history or the components of the evaluation not only undermines subsequent care; it may contribute to a perception of inattention to detail and a lack of credibility in any subsequent litigation.