Contact Us: 844-466-7225

Failure to Communicate a Significant Diagnosis Change Leads to Worsened Prognosis

March 26, 2021

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

Overview: Healthcare Communication: Case Studies and Best Practices for Communicating Critical Findings

Part 1: From Radiology to ED

Part 2: From Anatomic Pathologist to Ordering and Primary Care Physician

Part 3: From Primary Care Physician to Patient


The pathologist’s failure to notify the ordering physician of a cancer diagnosis delayed treatment and worsened prognosis.

Case File

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.

This content originally appeared as part of the March 2017 release of the NORCAL Group Risk Management publication, Claims Rx, “Communicating Critical Findings — A Three-Part Series, Part 2: Anatomic Pathologist to Ordering and Primary Care Physician.” This release and many others are available in the Claims Rx Directory for download. Policyholders will also find instructions for obtaining CME credit for select releases.


* 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

Filed under: Case Study, Patient Care



Interested in NORCAL Group?

Contact Your Agent/Broker or call 844.4NORCAL today