With the complexity of today’s healthcare environment, a pathologist may need to take a more active role in coordinating diagnosis communication than what may have been standard in the recent past. In the following case, the patient was never informed of a final diagnosis of malignancy after being informed the preliminary diagnosis was benign. Consider how the pathologists could have changed the outcome in this case.
More Information About Communicating Critical Findings along the Continuum of Care
Part 1: From Radiology to ED
- Closed Claim Case Study: Failure to Communicate Critical Radiology Findings Leads to Loss of Testicle
- Closed Claim Case Study: Failure to Close the Loop on Critical Findings Leads to Negligent Patient Death
- Closed Claim Case Study: Ambiguous Radiology Report Results in Below-the-Waist Paralysis
- Closed Claim Case Study: Failure to Follow Critical Results Reporting Policy Leads to Incorrect Diagnosis and Patient Death
- Best Practices: Develop a Process for Communicating Results Based on Criticality to Improve Clinical Decision-Making
Part 2: From Anatomic Pathologist to Ordering and Primary Care Physician
- Closed Claim Case Study: Prioritizing Urgent Diagnosis List Over Medical Judgment Leads to Patient Death
- Closed Claim Case Study: Failure to Directly Communicate Unexpected Cancer Finding Leads to Delayed Treatment
- Closed Claim Case Study: Failure to Communicate a Positive Biopsy Leads to Delayed Cancer Diagnosis
- Best Practices: Develop a Policy for Timely Diagnoses Communication to Facilitate Prompt Treatment
- Best Practices: Avoid Ambiguity in Pathology Reports to Improve Communication
Part 3: From Primary Care Physician to Patient
- Closed Claim Case Study: Lack of Redundancy and Coverage Contributes to Patient Death
- Closed Claim Case Study: Inadequate Follow Up on Abnormal Labs Leads to Permanent Injuries
- Closed Claim Case Study: Poor Test Result Communication Process Leads to Patient Injury
- Closed Claim Case Study: Failure to Convince Patient of Urgency of Follow Up Leads to Patient Death
- Closed Claim Case Study: Lack of Follow Up with “No Doc” ED Patient Leads to Patient Injury
- Closed Claim Case Study: Pre-Surgery Delay in Processing Abnormal Results Leads to Patient Death
The pathologist’s failure to notify the ordering physician of a cancer diagnosis delayed treatment and worsened prognosis.
CT scan revealed a mass in the patient’s liver. The gastroenterologist ordered a liver biopsy, which was completed by a radiologist, who sent the liver sample to pathologist #1. Pathologist #1 suspected hemangioma (a benign tumor), but he did not feel the biopsy was clearly diagnosable. He sent the specimen to pathologist #2 for further evaluation, and reported his preliminary findings to the gastroenterologist, who reported them to the patient and scheduled a six-month follow-up appointment. Pathologist #2 diagnosed adenocarcinoma compatible with cholangiocarcinoma, and sent a report to pathologist #1, who assumed pathologist #2 had communicated the results to the patient’s other physicians. No one informed the patient of the cancer diagnosis. The patient, believing her liver mass was benign, cancelled her follow-up with the gastroenterologist. One year later, the cancer diagnosis was discovered. By then the patient’s cancer had metastasized and was inoperable. The patient sued the gastroenterologist and the two pathologists for the delay in diagnosis and treatment.
Experts were in disagreement over which pathologist should have communicated the cancer diagnosis to the gastroenterologist. However, there was general agreement that, at a minimum, one of them should have informed the gastroenterologist and primary care physician (at the least as a matter of professional courtesy). If pathologist #2 had called the gastroenterologist or the primary care physician and informed either one that she had discovered malignant cells, the patient could have obtained necessary treatment and she most likely would not have filed a lawsuit. Experts were critical of the gastroenterologist for failing to follow up on the results.
Medical Liability Risk Management Recommendations
A physician who performs a biopsy or other procedure may not be further involved in the patient’s care and treatment. Sending a pathology report only to the last person in the treatment chain may result in a treatment delay. Consider the following recommendations:*
- Determine who on the patient’s treatment team should be notified of the patient’s diagnoses.
- If a pathology specimen is sent out for further pathological evaluation, establish who will notify the patient’s relevant clinicians. Document the communication agreement in the patient’s record.
- If a consultant pathologist will handle diagnosis communication, request copies of the reports. Follow up with the consultant if results are not received within a reasonable time frame.
- Tell referring physicians about the time needed for tissue processing or additional testing and whether the sample has been sent for a second opinion and to whom. Knowing when to expect a diagnosis can prompt appropriate follow-up.
- If a preliminary diagnosis has been communicated to the ordering physician, ensure that a significant change in that diagnosis is directly communicated to the physician.
- Circumvent communication failures by requiring ordering physicians to list all of the patient's relevant clinicians on pathology requisition slips, and request pathology reports be sent to the clinicians listed.
- Send pathology reports to physicians listed on pathology requisition slips.
More information about follow-up systems in general, including sample forms to facilitate effective follow up, is available to NORCAL policyholders in the NORCAL Risk Management resource, “Follow-Up.” Log in to MyACCOUNT or contact NORCAL Risk Management.
* Raouf E. Nakhleh. “Quality in Surgical Pathology Communication and Reporting.” Archives of Pathology & Laboratory Medicine. 2011;135:1394-1397. DOI: 10.5858/arpa.2011-0192-RA