A five-month-old girl was referred to the emergency department for evaluation of intermittent fevers and lethargy.
- William Berry, MD; CRICO/RMF; Cambridge, MA
The following case abstract is based on closed malpractice claims in the Harvard medical system. Some details have been changed to protect identities.
A five-month-old girl was referred to the emergency department for evaluation of intermittent fevers and lethargy. The infant was admitted for fever workup with laboratory studies suggestive of a urinary tract infection and possible pyelonephritis. The urine culture grew out E coli and the infant was started on intravenous Ampicillin and Gentamycin. A renal ultrasound to rule out hydronephrosis was ordered. During the night, the child spiked a temperature of 102 and was given Tylenol with good effect.
At 9:00 the next morning, the renal ultrasound revealed a 2x2 cm mass in the upper pole of her right kidney. According to the radiologist, the location and appearance of the lesion—as well as the age of the patient—made it suspicious for a Wilm's tumor. A progress note written by a pediatric resident listed the primary diagnosis as “UTI/pyelonephritis and renal mass.” The attending pediatrician reviewed the abdominal CT scan with the radiologist and confirmed the finding of a right renal mass, and no clear adenopathy (a chest CT scan was negative). The differential diagnosis at that point was Wilm's tumor.
After a pediatric surgical consult, the parents were told their daughter might have cancer and she needed surgery for either a heminephrectomy or complete nephrectomy.
On the morning of the third day, the patient was taken to the operating room. According to the operative report, the surgeon palpated the right kidney and noted only a subtle enlargement near the upper pole; he found the same result after mobilization. The kidney was removed and sent off for a frozen section.
According to the final pathology report, the right kidney had acute and chronic pyelonephritis The kidney lesion is commonly associated with reflux infection of E. coli which was cultured in the urine of this patient. There was no evidence of malignancy.
Although relieved that their daughter did not have kidney cancer, the parents were upset that she lost a kidney, seemingly unnecessarily. They sued the attending pediatrician, the radiologist, and the pediatric surgeon, and after unfavorable expert reviews, the case was settled in the high range.
To discuss the risk management and patient safety aspects of this case, Resource speaks with Dr. William Berry. Dr. Berry is a surgical consultant for CRICO/RMF, Harvard's medical malpractice and patient safety company.
Bill, thank you for joining us.
It's great to be here today.
When we look at the trajectory of the case, where did this problem originate? Where did it first start to ago awry?
Well, when the baby was admitted to the hospital, she was placed on antibiotics. All that care was completely appropriate. Before the baby was to go home, the pediatricians wanted to be certain that there wasn't some kind of anatomic problem that the baby had that would explain why at five months she got a urinary tract infection. So they appropriately ordered an ultrasound which was abnormal and the followed by a CT scan, and it was after they got the results of the CT scan that things start to veer off course.
At that point, Wilms tumor is added to the differential.
That's correct. As soon as Wilms tumor or the possibility of Wilms tumor is mentioned by the radiologist on the CT scan, the care of the baby kind of shifts away from an emphasis on the urinary tract infection and towards the consideration that the baby might have cancer.
And why was that so problematic?
Narrowing the diagnostic focus too much and then missing a possible but maybe not highly probable diagnosis—we see that commonly in both medical and surgical claims here. In this case, it's interesting because when the child comes in, the differential diagnosis is purely about infection, and the main diagnosis that's written in the record says pyelonephritis/urinary tract infection. Cancer is never mentioned in the initial considerations. It's not until after the radiologist puts “possible Wilm's tumor” that now the mass that they identified in the kidney now becomes a tumor and by implication cancer, and the consideration for infection just disappears totally. So what they've done is moved from a list of possible diagnoses of one—infection—to another list of possible diagnoses of one basically that it's some kind of tumor.
This narrow diagnostic focus that's too narrow doesn't just happen in surgery. It's throughout medicine as we see our malpractice claims. What are some top line key methods to prevent that from happening?
It really is all about keeping your mind open to other possibilities and forcing yourself into the exercise of actually creating a diagnostic list. It is very easy to drop to the thing that you think it is and really not think about other things. I mean, narrow diagnostic focus really is about considering other things that something could be. Again, the problem is that you see a patient and then you jump to a conclusion, justify it or not, and then that diagnosis then trumps everything else and actually probably keeps you from thinking about the other things that it could possibly be. When you are taught how to do differential diagnoses, you're taught to think of the thing that it probably is but then to consciously do an exercise to try and think of every other possible thing that this could be, something masquerading as something else.
Once the baby was in the operating room, was there another opportunity to find that diagnostic error?
Absolutely. The surgeon actually remarks in the operation report about how when feeling the kidney that the whole kidney feels the same and that he really can't identify a mass in the kidney. And he actually describes doing two things, examining the kidney before he separated it from the surrounding tissue and then examining the kidney again, and both times he was unable to find a mass. And then it appears that he just went ahead and performed the kind of the ultimate biopsy and removed the entire kidney. I think there probably were some alternatives for him.
Are there any of the techniques or the tools that we've started to see developed around surgical communication, around debriefs, any of those kinds of techniques that could have worked in this situation?
One of the things that might be and some of the things that we know about team training would be to create an environment in the operating room where the other people who are standing there and hearing the surgeon talk to himself could suggest maybe a different course of action. Clearly, the anesthesiologist and the nursing staff aren't capable on their own of giving an opinion about whether something is a cancer or not, but in the right environment, they might say something like ‘well, should you call in Dr. X, you know, maybe he should look in the field with you if you have some doubts.' Now in most of the operating rooms in the United States that's something that is very counter-cultural. But it is also something that I think a lot of places are working on to be able to create a level of trust amongst the people who do surgery to have that kind of frank communication whether he should continue with the surgery basically, that the best way to deal with that is to bring somebody else into the operating room and look in the field with you or even scrub into the case and feel the kidney.
The baby's parents decided to bring a lawsuit. They were told that their baby had cancer prior to the surgery.
So when you're operating because there is a tumor present and you don't know for sure what the tumor is, a very important part of the preparation of the patient then is to share that information with them because there's always a chance that it might not be a tumor at all. Patients then reflect back on the operation and if they go into it thinking that it's a cancer for sure, when they come out and it's not a cancer, then they are going to think they had an operation for no reason. Where if they're prepared in a different way that it may be a cancer, but it may not be a cancer, when you come out and can tell them that it's not a tumor, they share your joy that they didn't have a cancer rather than looking back at the surgery like I never should have had this in the first place.
Can the consent process which sounds a lot like the differential process actually help prevent a narrow diagnostic focus?
It potentially could because in thinking about all the possible outcomes of a procedure that you're about to perform, it kind of forces you to think about all the different things that could be causing what you're about to operate on so that the two ideas are aligned in a way. I don't think right now in the current state of medicine that that probably happens very often because once the decision is made to do surgery, if anything, the diagnostic focus most of the time cranks down even more, but it is certainly a possibility. I think avoiding the narrow diagnostic focus is either about forcing yourself to think all the way through something or, you know, having some thing like getting consent be a trigger for you to think about things, outcomes of the procedure or causes of the reason why you're gonna operate that will bring to mind things that you haven't considered fully.
Thank you, Dr. William Barry, Surgical Consultant for CRICO RMF. For resource, I'm Tom Augello.
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