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Prioritizing Urgent Diagnosis List Over Medical Judgment Leads to Patient Death

March 26, 2021

In the following case, the pathologist’s finding was not listed on the urgent or unexpected diagnoses lists so she did not directly contact the ordering physician to report her findings. However, a number of experts in the malpractice suit that followed believed the pathologist should have done so. Consider how the outcome could have been different if the pathologist had used her medical judgment and focused on patient safety.

Doctor reading a pathology reportAllegation

The pathologist should have informed the radiologist that the pancreas biopsy had no pancreatic tissue but included intestinal and gallbladder tissue.

Case File

A patient presented to a radiologist for a pancreas biopsy. The radiologist did not realize he perforated the intestine and gallbladder and failed to obtain tissue from the pancreas. The radiologist sent the sample to the pathologist. In the recovery room, the patient reported pain and nausea and was vomiting but she was discharged. The next day, her family reported her worsening symptoms to the radiology office, but they were told to follow up with the patient’s primary care physician, who suspected the patient was suffering from influenza.

The pathologist found no pancreatic tissue in the sample, but instead the sample included fragments of gallbladder and intestinal tissue. The pathologist dictated and handed her report to a secretary. She assumed the secretary would fax the report to the appropriate physicians the same day. She did not know who the report would be sent to and did not confirm receipt of the report.

The patient died one week after the biopsy. The autopsy found perforation of the colon and gallbladder, both of which contributed to bilious peritonitis, the cause of death. The patient’s family filed a lawsuit alleging the radiologist negligently performed the biopsy, the radiology center should have recognized the signs of peritonitis, and the pathologist should have known that the sample indicated the patient was at significant risk for peritonitis. If the pathologist had called the radiologist or primary care physician, they argued, they would have reassessed the patient’s abdominal pain and nausea, and the peritonitis would have been discovered and successfully treated.


Although the radiologist and radiology center staff were the target defendants in this case for various reasons, the pathologist missed an opportunity to prompt a lifesaving diagnosis. Experts disagreed on whether the standard of care required the pathologist to directly communicate the results but stated they personally would have called the radiologist. Failure to observe expected tissue in a pathology sample is not in itself a finding requiring urgent intervention. However, the finding of the intestinal and gallbladder tissue should have prompted the pathologist to make a telephone call to the radiologist, which would have been reasonable and in the patient’s best interest.

Medical Liability Risk Management Recommendations

Consider the following recommendations when reporting clinically significant pathology results:

  • Immediately and directly communicate clinically significant and time-sensitive diagnoses to the ordering physician and, if necessary, the primary care physician.
  • Be familiar with the lists of urgent and significant, unexpected diagnoses, as well as the reporting policies and protocols in your practice environment.
  • Use clinical judgment. Do not be dissuaded from direct communication by the absence of the diagnosis on an urgent diagnosis list.
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.

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

Filed under: Patient Care



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