Incidental findings of lung nodules are common and frequently missed. Many of these missed nodules are clinically irrelevant.1 However, when a patient who is diagnosed with advanced lung cancer discovers there was an unreported incidental finding during a period when the lung cancer was treatable, a negligence claim is likely. Consider how improved communication could have affected the outcome of the following radiology case study.
Allegation
The orthopedic surgeon failed to review or follow up on the results of a preoperative chest x-ray, which resulted in a delayed diagnosis of lung cancer.
Case File
A 60-year-old patient presented to an orthopedic surgeon in 2013 with complaints of left hip pain. X-rays of her left hip showed severe osteoarthritis. After a year of conservative therapy, plans were made for hip arthroplasty. In January 2014, the patient underwent a preoperative chest x-ray, which was ordered by the orthopedic surgeon for the benefit of the anesthesiologist. The chest x-ray was interpreted by Radiologist 1, who noted a 2 cm ill-defined density in the right lung. Radiologist 1 recommended further characterization by CT. The report was filed in the patient’s hospital chart, and the surgery was completed with no complications.
In 2016, the patient was scheduled for a right hip arthroplasty with the same orthopedic surgeon. He again ordered a preoperative chest x-ray for the benefit of the anesthesiologist. Radiologist 2 noted a slight interval enlargement of the right lung density when compared to the January 2014 study. This time, a copy of the report was sent to the orthopedic surgeon’s office. The orthopedic surgeon’s medical assistant noted the density and sent the report to the anesthesiologist, asking him to confirm that the patient was still cleared for surgery. The anesthesiologist cleared the patient for surgery but also ordered chest CT follow-up. Shortly thereafter, the patient was diagnosed with lung cancer. Although the patient underwent lobectomy and chemotherapy, she died as a result of the lung cancer. The patient’s family filed a wrongful death lawsuit against all members of the healthcare team, alleging they shared responsibility for the delayed lung cancer diagnosis.
Discussion
The incidental finding of lung cancer slipped through the cracks because responsibility for preoperative chest x-ray results was not well defined. Depositions of the various members of the patient’s healthcare team revealed a number of dangerous practices. For example:
- Once radiologists or radiologic technologists entered study impressions into the EHR, they considered their duty to patients fulfilled. However, if there was a significant enough finding (the level of significance was not defined in policies and varied from radiologist to radiologist), a radiologist would call the ordering physician.
- The defendant orthopedic surgeon believed the operating room nurse reviewed all of the preoperative studies, which was not true.
- Because he ordered the chest x-ray for the benefit of the anesthesiologist, the orthopedic surgeon took no responsibility for following up on the results. He believed the anesthesiologist was responsible for the chest x-ray results, and it was not his practice to review the chest x-rays — he only reviewed x-rays of the surgical site. However, other members of a patient’s health- care team frequently flagged abnormal chest x-ray findings and brought them to his attention, at which point he would follow up. This supported his belief that he was not responsible for independently following up on the preoperative chest x-rays he ordered.
- Because the anesthesiologist felt his role was limited to determining whether the patient was healthy enough for the surgical procedure, he did not follow up on incidental chest x-ray findings. He believed the orthopedic surgeon was responsible for follow-up because he had ordered the x-ray.
Experts who reviewed this case noted that every member of the healthcare team had an opportunity to act on the abnormal findings. Each defendant was expected to argue that the standard of care did not require him or her to follow up on the chest x-ray abnormality. (This was a particularly difficult position for the orthopedic surgeon, since he ordered the study.) However, the fact remained that the cancer went undiagnosed, and a jury would attribute negligence to one, some or all of the defendants. Furthermore, the defendants would have to convince the jury that the other defendants were negligent in order to exonerate themselves. Blaming other members of the healthcare team usually inflates jury verdicts and settlement values. Because of these and other issues, the defendants determined settlement was the best resolution of this claim.
Medical Liability Risk Management Recommendations for Ordering Physicians
Consider the following recommendations:1,2,3,4
- Do not order studies if the results are not relevant to you or if you do not plan to review the results.
- Create a written imaging request that is clear and concise.
- Provide the radiologist with relevant clinical information, suspicious findings and your impressions.
- Do not assume someone else will follow up on the tests you order unless it is established in a written protocol.
- Establish a dependable follow-up system to determine whether patients have undergone the recommended tests and if so, whether the results have been received and acted on.
- Take responsibility for resolving any problems associated with the radiology studies you order (e.g., delayed receipt of the radiology report, seeking clarity for unclear impressions in the report and findings inconsistent with the patient’s presentation or follow-up that seems inappropriate).
- Document efforts to resolve these issues in the medical record.
- Review the complete radiology report; incidental findings may not appear in the initial commentary.
References
1. Burt JR, Iribarren C, Fair JM, et al. Incidental findings on cardiac multi-detector row computed tomography among healthy older adults: prevalence and clinical correlates. Arch Intern Med. 2008; 168:756–761.
2. Hanna D, et al. Communicating critical test results: safe practice recommendations. Jt Comm J Qual Patient Saf. 2005;31(2):68-80. (accessed 3/27/2017)
3. Singh, H. and M.S. Vij, Eight recommendations for policies for communicating abnormal test results. Jt Comm J Qual Patient Saf. 2010;36(5): 226-32.
4. Laing D, Now L. A Radiologist’s Duty to Communicate with the Treating Physician. Health Law Litigation. 2010 Winter;8(1):1-6.
