Diagnostic Errors

by Laura Hale Brockway, ELS

Article originally posted by Texas Medical Liability Trust

Presentation

A 67-year-old man was admitted to the hospital at 2:40 p.m. under the care of an internal medicine physician. The patient had a history of abdominal pain, nausea, and vomiting for several days. The internal medicine physician wrote admission orders with a diagnosis of acute pyelonephritis. He ordered a gastroenterology consult and a CT scan of the abdomen to rule out kidney stones. He also ordered a full liquid diet for the patient. The physician had not seen or evaluated the patient when these admission orders were written.

Physician action

At 5:08 p.m., the internal medicine physician assessed the patint. He revised the admission orders, changing the diagnosis to “acute gastroenteritis.” The internal medicine physician also changed the order for the CT scan to include contrast and changed the status to “stat.”

A gastroenterologist saw the patient at 7:20 p.m. He ordered an EGD to be performed the next morning. His progress notes indicated that he was aware the CT scan was pending. The gastroenterologist contacted the internal medicine physician to discuss his plan to perform the EGD.

At 7:44 p.m., the CT scan report became available in the hospital’s electronic medical record system. The results indicated a partial small bowel obstruction. A copy of the CT report was also printed on the surgical floor so the report could be placed in the patient’s chart.

At 11:10 p.m., a nurse on the surgical floor logged in to the hospital computer system and printed a copy of the CT report. However, neither this paper copy nor the one that printed when the CT report was generated, made it to the patient’s paper chart. The internal medicine physician logged on to the hospital’s EMR system at 11:15 p.m. and ordered a surgical consult. The plaintiffs later alleged that the internal medicine physician knew about the results of the CT scan, which explained why he ordered a surgical consult.

Nursing notes throughout the evening indicate the patient’s abdomen was distended with no bowel sounds. The patient vomited once and complained of indigestion.

At 5:30 a.m., the patient signed a consent form for the EGD. A nurse examined him 30 minutes before the EGD and documented that his abdomen was distended with no bowel sounds. The gastroenterologist accessed the radiology records in the computer system at 8:22 a.m. for approximately 22 minutes. He claims he did not see the CT report. The patient was already in the endoscopy suite and anesthesia commenced at 8:30 a.m. The procedure began and the patient began vomiting violently after the endoscope tube was inserted. The gastroenterologist suctioned 700-800 cc of stomach contents with an NG tube. The patient was taken to the PACU. He was later intubated and transferred to the ICU on ventilator support due to aspiration of stomach contents.

The patient had a long hospital course. He experienced multiple complications including aspiration pneumonia, ventilator requirements, and deconditioning. The partial bowel obstruction resolved without surgical intervention.

Allegations

Lawsuits were filed against the gastroenterologist, the internal medicine physician, the radiologist, the anesthesiologist, and the hospital. The plaintiffs alleged that the EGD was contraindicated because the CT scan showed a dilated bowel and possible bowel obstruction.

Legal implications

The CT scan of the abdomen showed a small bowel obstruction. This report was available on the hospital’s computer system the night before the scheduled EGD. The access log shows that the gastroenterologist logged in to the system on two occasions after the CT report was in the system, but he apparently failed to see the CT report.

A nurse’s note — written approximately 30 minutes before the procedure — documented that the patient’s abdomen was distended with no bowel sounds. This note was available on the hospital’s system and the patient’s chart. The gastroenterologist testified that, when he examined the patient just before the procedure, his abdomen was not distended. This was not documented in the medical record.

Additionally, the gastroenterologist had to acknowledge that he was aware that a CT scan of the abdomen had been ordered, but he went forward with the EGD without knowing the results. He also testified that, had he known the CT report showed a partial bowel obstruction, he would have cancelled the procedure.

The internal medicine physician re-wrote the admission orders to change the diagnosis from pyelonephritis to gastroenteritis. He also changed the CT order to “stat.” The gastroenterologist did not follow up on these results, and he claimed that he never saw the results of the CT scan. The plaintiffs argued that he must have known about the CT findings since he ordered a surgical consult.

Disposition

The cases against the radiologist and the hospital were dropped. The cases against the gastroenterologist and the internal medicine physician were settled prior to trial. The case against the anesthesiologist went to trial and the jury found in favor of the anesthesiologist.

Diagnostic errors

Efforts to improve patient safety often address issues such as medication errors, nosocomial infection, wrong-site surgery, postsurgical complications, and hand-offs. Diagnostic error — which is the leading cause of malpractice claims against primary care physicians — has received comparatively less attention. (1)

This article will review the current research on the prevalence of diagnostic errors, identify common causes of diagnostic errors, and discuss ways to prevent these types of errors.

View the full article on TMLT.org–>