A misread X-ray of patient with pneumonia led to respiratory failure and death

Diagnostic Testing: Case Example

A 55-year-old male was diagnosed by his primary care clinician with sinusitis and prescribed an antibiotic. Six days later, he was evaluated in an urgent care clinic for shortness of breath, labored breathing, extreme fatigue, and chest pain with cough. The patient had a temperature, a fast heart rate, and low oxygen saturation. After he was treated with an aerosolized nebulizer, his oxygen saturation improved. Based on her negative interpretation of a chest X-ray, the urgent care clinician diagnosed a viral URI and instructed the patient to see his family doctor the next day.

Two days later, the X-ray was read by a radiologist with impression of pneumonia. The clinic called the patient and instructed him to go to his local Emergency Department for evaluation and treatment. Before he could get to the ED, the patient died of respiratory failure associated with pneumonia.

(Case settled: $110K)

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Excerpted from 2014 Annual Benchmarking Report, Malpractice Risks in the Diagnostic Process.
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