Malpractice Case: Missed x-ray finding

[bbc586]

Case 8: Cough – medmalreviewer

Patient seen for cough. Radiology read mentions incidental finding.
No follow-up until several years later, patient's incidental finding now developed into inoperable cancer.
Patient sues. Doc has died in the meantime, so they're really just suing his estate. Lawsuit dismissed due to statute of limitations.

I'm guessing the doc looked at the xray, searching for pneumonia, did not see any, so discharged the patient. Radiology report came back after already discharged, no one ever looked at the report, missed the incidental finding.

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[southerndoc]

This is an increasing trend.

 

[RustedFox]

Has happened once or twice at my shop as well.
I now have an AutoText to deal with the incidentals to make it fast and easy to chart.

 

[Groove]

It's funny, as emergency physicians none of us are typically really focused or worried about these incidental findings as we're trying to rule out the emergent stuff, but these things are just as medico legally prone to suit if someone is diagnosed with cancer or some other condition and the last XR or CT they received was in the ED but they weren't told about X,Y,Z incidental finding.

In Cerner, I always make sure the Counseled section is filled in where it states that I counseled pt regarding dx, regarding all diagnostic results, regarding treatment plan, etc.. (I think that probably covers me to some degree)

I also am liberal with putting in diagnosis for incidental findings, it might be "pulmonary nodule", "liver lesions" or if it's something bizarre that's uncodable I'll do "Abnormal abdominal CT" or "Abnormal chest XR", etc..

The problem lies in shops like mine where we have wet reads at night which typically don't point out incidental findings. Same goes for plain films which are not read until 7a.m. If someone gets d/c and they notice a pulmonary nodule then it's up to you to inform the pt. We have a system where the radiologists will flag these as "ED Positives" and make a list to be given to the 6a.m. doc to review to see if anyone needs to be called and/or updated. It's an imperfect system but it's the best we've got at the moment. Luckily, our rads dept has a contract submitted for 24/7 reads with a nighthawk service and I'm keeping my fingers crossed.

 

[MechEDoc]

It's complete BS that radiology can work office hours and then leave other physicians on the hook for their scut work.

I inform every patient in writing that their visit was limited to emergent conditions only and that there are many subtle things that may require further care* and to follow up with their PCP for review their entire visit. Probably doesn't change my liability, but I sleep a little better. It's kind of like suing Jiffy lube that they didn't warn you about your impending head gasket failure. But "if only you had sent the oil for analysis, trace antifreeze would have been found saving the engine's life! Won't anyone think about the premature death of my engine!!!... Members of the jury, just one simple test would have saved this fine engine."

* I read somewhere about an ED physician being sued for a one point hemoglobin drop with a slight increase in MCV since the last labs a year or more earlier. The lawsuit alleged malpractice in that the ED physician didn't refer the patient for a colonoscopy to catch their indolent cancer. WTF?

 

[GonnaBeADoc2222]

I used to aggressively chart and account for every little ditzel on radiology and labs but realized there's no point. All I can do it my best. The plaintiffs lawyers and jackpot seekers will get you for something eventually and it's not even my money at risk so why expend the extra effort trying to avoid it.

 

[Groove]

I used to aggressively chart and account for every little ditzel on radiology and labs but realized there's no point. All I can do it my best. The plaintiffs lawyers and jackpot seekers will get you for something eventually and it's not even my money at risk so why expend the extra effort trying to avoid it.

20-44 months average length of litigation depending on outcome. 20-40+ hours in defense preparation.

Versus a few secs to add a couple smartphrases and/or look back over the reads and schedule the relevant f/u.

You tell me which sounds harder.

That being said, I'm really only focusing on the relevant stuff, not each and every single abnormality (non calcified pulm nodule, liver mass, etc..). The H/H example sound ridiculous. Hopefully that got dropped quickly.

 

[GonnaBeADoc2222]

20-44 months average length of litigation depending on outcome. 20-40+ hours in defense preparation.

Versus a few secs to add a couple smartphrases and/or look back over the reads and schedule the relevant f/u.

You tell me which sounds harder.

That being said, I'm really only focusing on the relevant stuff, not each and every single abnormality (non calcified pulm nodule, liver mass, etc..). The H/H example sound ridiculous. Hopefully that got dropped quickly.

Of course, that's just good medicine. But I'm not gonna account for every borderline normal-low sodium or every benign renal cyst.

 

[MechEDoc]

I'm not gonna account for every borderline normal-low sodium.

I had some a**hole chart reviewer send a nasty gram to me about not doing something about a low normal sodium. They were patronizing enough to copy and past from UptoDate about sodium. I think it was some nurse who was plowing through charts and thought she was being smart. I wrote them back - on shift at my regular rate - kindly pointing out that normal sodium in cirrhosis is different from the rest of the population, offered suggestions on how to read UptoDate (to find the correct section) and generally how to go f-themselves. Pretty sure it fell on deaf ears. However, I did have someone try to account for a low normal sodium. Ugh.

 

[miacomet]

I give every patient a CD of their imaging and tell them to review it with their doctor.

I agree this is a medmal hellhole. Outta the game soon. Not worth it.

 

[deleted859535]

I give every patient a CD of their imaging and tell them to review it with their doctor.

I agree this is a medmal hellhole. Outta the game soon. Not worth it.

I forget - in what state do you practice?

 

[miacomet]

My state is fairly medmal friendly. Why?

 

[deleted859535]

My state is fairly medmal friendly. Why?

Because you're one of the more outspoken critics of EM, and I just wondered if there would be a relationship. No offense intended, of course -- you've probably been in it longer than me, lord knows EM isn't all roses, and we all have different tolerances to this occasional goat rodeo as Panda Bear would've put it.

 

[miacomet]

Because you're one of the more outspoken critics of EM, and I just wondered if there would be a relationship. No offense intended, of course -- you've probably been in it longer than me, lord knows EM isn't all roses, and we all have different tolerances to this occasional goat rodeo as Panda Bear would've put it.

I work in a unicorn job; time invested, so I'll slog for a bit longer, especially with the squishy job market. I'm just honest with myself that EM is not that great a ROI.

In a good situation, just honest about the blemishes.

 

[Groove]

I give every patient a CD of their imaging and tell them to review it with their doctor.

I agree this is a medmal hellhole. Outta the game soon. Not worth it.

That's awesome. The radiology techs must hate it when you're on shift, LOL.

 

[GeneralVeers]

That's awesome. The radiology techs must hate it when you're on shift, LOL.

Yeah I think the techs would have me murdered if I did this.

 

[miacomet]

No, this is standard at our facility. There are signs in the rooms telling patients to request a CD with their images.
Our standard DC instructions (that no one reads, but that's their problem at least) state that this was an ED evaluation and that it's not comprehensive, so patients must follow up with their "provider."
I wish I were better at putting EVERYTHING in the DC paperwork- I sometimes forget, for I am human. To that end, our system is working on a mechanism to automatically notify in-system PCPs of incidental findings.

I would suggest you bring up the CDs, DC instructions, and PCP notification with administration. It would help their bottom line, too.

 

[Apollyon]

That's awesome. The radiology techs must hate it when you're on shift, LOL.

I can make the disc from my computer. They just have to bring it over.

 

[miacomet]

I can make the disc from my computer. They just have to bring it over.

This is a waste of doc time

 

[Groove]

I can make the disc from my computer. They just have to bring it over.

That sounds like an eternity. I already sacrificed my scribe after my CMG started charging us $15/hr for their services. The last thing I need is to be stuck burning CDs at my desk like in my college days after downloading gobs of music on Napster. I hate burning CDs.

 

[Apollyon]

This is a waste of doc time

I'm efficient (a/k/a "f****** around on the computer"). Honestly, it takes 4 clicks.

 

[miacomet]

I'm efficient (a/k/a "f****** around on the computer"). Honestly, it takes 4 clicks.

Better four clicks by the tech than me. Seriously, I'm disturbed more hospitals don't make a CD standard.

 

[GonnaBeADoc2222]

I can make the disc from my computer. They just have to bring it over.

I would just be careful that this is "allowed." Could this somehow violate HIPAA? Sort of like how patients who are docs/staff cannot access their own medical records - they need to request from medical records.

 

[Apollyon]

I would just be careful that this is "allowed." Could this somehow violate HIPAA? Sort of like how patients who are docs/staff cannot access their own medical records - they need to request from medical records.

It has been vetted by UPMC, so, I am confident. This has always been the policy (giving discs) for the nearly 5 years (in June) I've been at this job. And, likewise, UPMC says you can access your own record (except for HIV, psych, and drug and alcohol treatment), without having to make a records request.

It's mostly ortho, when we don't have ortho coverage, so the pts are given their own images on a disc, or it's given to EMS to take (if it is transfer, instead of discharge). And making the disc is right in the VRAD client - I select the study, click on the "forward" arrow, and that takes me to the next screen. I check "PacsGearCD", and then forward, and that makes the disc. The rad techs do the exact same thing. I don't use the generic login for the PACS viewer - I had them create my own.

FWIW, my place is slow - it averages 2pph for 8-10 hours, then really chills out (but, with the FM folks, the bouncebacks are pronounced for whomever is the doc working the next day).

 

[miacomet]

I would just be careful that this is "allowed." Could this somehow violate HIPAA? Sort of like how patients who are docs/staff cannot access their own medical records - they need to request from medical records.

More like getting records from MyChart, I think.