How We Can Help

• Car Accidents
• Nursing Home Injury
• Medical Malpractice
• Child Injuries

Videos

Medical Malpractice:

• Make Sure The Doctor Give You This Blood Test If You Might Be Having a Heart Attack
• What To Do If My Heart Attack Looks Like The Flu | Deltona Malpractice Lawyer
• Undiagnosed Epidural Hematoma Can Cause Cuada Equina Syndrome
• ACL Surgery Injures Femoral Nerve
• Is Cutting My Bladder While Removing My Uterus Medical Malpractice?

View All

X-ray Mistake Delays Cancer Diagnosis, Leads to Death and $2 Million Settlement

The medical resident thought he had cancelled the X-ray order for the patient.

However, the radiologist who performed the X-ray noticed a small mass and requested a follow-up CT chest scan in the report he sent to the ordering physician.

Because the medical resident was not expecting it, he never reviewed the X-ray report. This mixup delayed by 3 years the cancer diagnosis for this patient, resulting in a poor prognosis and ultimately death for the patient.

During pre-hernia surgery evaluation of this 41-year-old female, the surgical resident wrote orders for a chest X-ray among other things. The chest X-ray order was later crossed out after the resident spoke with the patient and learned that she had undergone testing and a cardiology consult as part of a work-up for her palpitations.

The resident reviewed the pre-operative test results before surgery and determined that they were within normal limits. The patient underwent surgical repair of her hernia without complications.

Three years later, the patient arrived at the same hospital seeking treatment for chest pain and shortness of breath. A chest X-ray was ordered and compared to one done three years earlier — the chest X-ray that the surgical resident thought had been canceled.

Although the resident had crossed out the order for chest X-ray, he forgot that the requisition slip had already been filled out and given to the patient who had the test performed. That chest X-ray revealed a suspicious elevation of the patient’s diaphragm.

The radiologist did not report a definite mass but there was a slight increased density in the area of the mediastium, and he recommended a follow-up chest CT scan. The radiologist’s practice at the time was to batch copies of X-ray reports and send them to the ordering providers. The ordering provider in this case was the surgical resident, who does not recall ever seeing the test result. Nor was he looking for the result, since he thought he canceled it.

The new chest X-ray revealed a large mediastinal mass with elevation of the left hemidiaphragm as well as left-sided pleural based masses. A biopsy later revealed metastatic cancer. After diagnosis, the patient underwent two surgeries, radiation treatments and chemotherapy to no avail. She died within a year of diagnosis.

The patient’s estate sued the surgical resident and the hospital, alleging that negligent failure to act upon an abnormal chest X-ray resulted in a three-year delay in diagnosing the cancer. The delay allowed a cancer that was potentially very treatable/curable to advance to a terminal stage for this patient.

This case settled for more than $2 million against the hospital and the surgical resident.

This was a successful medical malpractice lawsuit based on the following factors:

Lack of formal process for test results. Because the resident no longer expected a chest X-ray, he never looked for results. Providers need a reliable process to verify what preoperative testing has been conducted, make sure that all results – including incidental findings – have been reviewed prior to surgery, and execute or arrange for any follow-up deemed necessary.

All reports and tests must be reviewed. The ordering doctor must fully review imaging reports and follow-up on all significant findings, regardless of the purpose of the test.

Inadequate communication. The radiologist noted that the X-ray findings were abnormal, but did not believe they were immediately life-threatening. He chose to send a copy of his report and recommendations to the resident, rather than speak to him or the patient personally. Poor communication and follow-up systems can lead to tragic errors, as in this case. Ordering physicians can be re-assigned, resident rotations change, and ordering clinicians may not be looking for problems buried in “routine” test results. If ever in doubt, radiologists should choose to err on the side of caution and verbally contact the ordering provider with unexpected worrisome findings. And those conversations should be documented.

For more on patient safety issues, see the library of articles by Daytona Beach medical malpractice attorney.

Your Questions Answered