Following several days of care in various settings, a 43-year-old man with a history of abdominal pain died while being intubated.

Key Lessons

  • The fragmentation of contemporary health care systems means providers frequently lack critical information when making treatment decisions.

  • Examination of “near-misses” can alert managers of the need for new methods to ensure proper management of test results.

  • A patient being seen by multiple providers cannot be treated as “everyone’s” responsibility.

  • A patient with a chronic disease who presents with an acute episode is among the hardest to diagnose.

Clinical Sequence

On Monday, a 43-year-old obese male presented to the emergency department (ED) with severe abdominal pain, vomiting, and chills. He described six previous episodes. An extensive diagnostic work-up that included a small bowel series, CT scans, colonoscopy, and laparotomy, failed to identify a definite cause of his pain.

The ED physician interpreted the KUB (kidney, ureter, and bladder X-ray) as not indicative of a small-bowel obstruction. The patient received pain medication and intravenous fluids and was instructed to see his primary care physician PCP) if his symptoms persisted. The ED physician informed the PCP who, as a result of a recent insurance change, had not yet seen (or met) this patient. The PCP dictated a note for the patient’s medical record.

On Tuesday, the patient presented to the PCP’s office with continued nausea. The physician on duty (who was not the PCP contacted the night before) had a copy of the ED report faxed to his office. Relying on the report that the KUB was normal, he neither ordered further X-rays nor obtained a surgical consult. Simultaneously, the hospital radiologist dictated her report on the KUB stating “several moderately distended loops of small bowel in the right upper quadrant which may represent a small bowel obstruction; follow-up films recommended.” The Radiology report went directly to the patient’s record, but not to the ED or the PCP (or the covering internist).

Over the next two days, two physicians and a physician assistant (PA) examined the patient. Palliative treatments provided temporary relief, but multiple tests and exams failed to fully identify the source of his abdominal pain. The PA did find out—and noted in the record—that a laparotomy done several years prior showed this patient had sarcoid adhesive disease.

Early Friday morning, the patient, now acutely ill, was rushed to the ED with abdominal pain, nausea, vomiting, and a new problem—shortness of breath. The surgeon on call obtained the chronology of events since Monday, as described by the patient. Unaware of the patient’s history of sarcoid adhesive disease, the surgeon elected to rule out a pulmonary embolism and ordered a VQ scan followed by an abdominal CT scan. He then left to see other patients.

Friday evening, the surgeon returned to see the patient and learned of an earlier hypotensive episode, abnormal blood work, and the CT scan performed in the late afternoon. The patient was prepped for surgery, but suffered a brief run of ventricular tachycardia followed by atrial fibrillation. Resuscitative measures were unsuccessful. Autopsy identified that the cause of death was a strangulated bowel.

Claim Sequence

Suit was filed against PCP and two covering internists, the surgeon, and the PA, alleging failure to diagnose and delay of lifesaving surgery. The PA was later dropped from the case


This case was settled for more than $1 million.


  1. The patient in this case was seen by four physicians over four days, and was also examined by a physician’s assistant. Although all five were named in the lawsuit, the settlement was allocated against the surgeon and the internist covering for the PCP (who had never encountered this patient). As a result of the fragmentation of contemporary health care systems, providers frequently lack critical information when making treatment decisions. Paper-based office records can cover care provided there, but often lack information pertaining to care outside the office practice (e.g., ED visits, or discharge summaries). A computer-based patient record can bridge current medical information needs at any site, reducing the potential for incorrect decisions.

  2. The Radiology report did not reach the providers who would have benefited most from reviewing it. Lag times in getting clinical information into the right hands can lead to diagnostic delays…and sometimes avoidable patient harm. Failures of systems in the Radiology and Emergency departments in the transmission and follow-up of abnormal test results are perilous. Examination of “near-misses” can alert managers of the need for new methods to ensure that results of tests are correctly directed, received, and acted upon to prevent harm to patients.

  3. The surgeon was unaware of crucial information (about sarcoid adhesive disease) elicited by the PA until it was too late. When a patient is admitted to the hospital, communication between the surgeon and the ambulatory care providers often guides the patient’s care. While the ideal health care setting, where all disciplines work together in a coordinated fashion, may not be realistic, all providers who “hand off” or receive a patient (or information about the patient) have an obligation to do so carefully—and to confirm the exchange.

  4. Without a definitive diagnosis for so long, the providers still providing care really seemed to be out on a limb. The providers were ordering the proper blood work, X-rays, and so forth, but the information wasn't being shared with the progression of providers that saw the patient. A patient being seen by multiple providers cannot be treated as “everyone’s” responsibility. The patient—and all of the providers involved—benefit most when all are clear about who is responsible for following the patient (and information related to that patient) across all his or her interactions related to the initial presentation.

  5. This patient's symptoms evolved from chronic to acute, accelerating the need for a definitive diagnosis and treatment plan. Instead, the lack of coordination and miscommunication hindered his assessment and delayed his treatment. Even the most experienced physicians feel that a patient with a chronic disease who presents with an acute episode is among the hardest to diagnose. One practice that can help is to have in place a protocol for patients with chronic conditions who suddenly change their care seeking pattern. Avoidable patient harm may be prevented if providers have a trigger that alerts them that they need to stop and reevaluate whether the current symptoms were part of the chronic problem or a brand new one.


Written By: Kathleen Dwyer, R.N. Senior Loss Prevention Specialist, CRICO (for Forum, July 2002) and Jock Hoffman (December 2006)

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