Failure to communicate test results

Presentation

A 42-year-old man came to an urgent care clinic for an injury he sustained while playing basketball. He reported pain in his right calf.

Physician action

The urgent care physician documented swelling and a 2+ palpable dorsalis pedis pulse. She diagnosed a muscle tear and possible deep vein thrombosis (DVT). The patient was sent for a venous duplex ultrasound, which was read as showing a right peroneal vein DVT. The patient was directed to a hospital emergency department (ED).

At the ED, the patient was examined and found to have tenderness with passive range of motion and swelling. His right calf circumference was measured at 49 cm and his left calf was measured at 44 cm. The patient was admitted by Hospitalist A, who ordered enoxaparin and requested a consult with an orthopedic surgeon.

Orthopedic Surgeon A saw the patient that day and noted the patient had pain, palpable dorsalis pedis pulse, and intact sensation. He documented that the patient had a muscle tear and no compartment syndrome.

The next day, Orthopedic Surgeon A examined the patient again. He documented pain, swelling, and no compartment syndrome. He ordered an MRI. Later that morning, a physical therapist documented that the patient had decreased sensation with numbness, swelling, and tingling in his right calf.

At noon, a nurse documented that the patient had diminishing posterior tibial signal and had difficulty moving his toes. The patient was unable to feel when his toes were touched, though a palpable pedis pulse was noted. The nurse also noted the patient’s need for an increasing amount of pain medication.

Hospitalist A was notified, and she ordered a STAT CT scan and a CT angiogram of the right leg at 6:18 p.m. For an unexplained reason, the STAT order was changed to “Routine.”

Radiologist A reviewed the CT images at 10 p.m. He reported the patient had no flow in the right popliteal artery and no flow more distal in the anterior tibial artery. These results were not reported to Hospitalist A or the nursing staff.

The next morning, Hospitalist A saw the patient and documented that he could no longer move his right toes. After reviewing the CT report, Hospitalist A contacted Vascular Surgeon A for a consult. Vascular Surgeon A gave a phone order to hold the patient’s enoxaparin. He then performed a fasciotomy due to a presumptive diagnosis of compartment syndrome.

The next day, the patient reported numbness and an inability to move his right leg. Vascular Surgeon A took the patient back to surgery and repaired a bleeding vessel in the right calf. Over the next several days, the patient underwent several procedures due to continued numbness and inability to move his leg.

The patient’s condition worsened. Two weeks later, he had a right above-the-knee amputation due to necrosis of the right calf and foot.

Allegations

A lawsuit was filed against Radiologist A, alleging failure to timely notify the ordering physician about the critical and urgent results of the CT. Lawsuits were also filed against Hospitalist A, Orthopedic Surgeon A, Vascular Surgeon A, and the hospital.

Legal implications

During the review of this case, there was much discussion among the experts and treating physicians about Radiologist A’s duty to directly communicate the results of the CT scan. According to the physicians who were following the patient, the CT results were a critical finding that should have been communicated promptly with a phone call instead of a routine report.

Hospitalist A stated it was her expectation that the CT results would be available within the hour. When her shift ended at 7 p.m., she “checked out the plan, including the pending stat CT, to her night coverage.” When Hospitalist A arrived the next morning, she found the CT had been changed to routine and the results were never called in to the night coverage.

A radiologist who reviewed this case was supportive of Radiologist A’s action. It was this radiologist’s opinion that clinicians have a duty/responsibility to obtain the results of the tests they ordered.

Disposition

The case against Radiologist A was settled. The cases against Hospitalist A, Orthopedic Surgeon A, and the hospital were also settled. The outcome of the case against Vascular Surgeon A is unknown.
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More about communication errors.
Risk management for radiologists.
Risk management for orthopedic surgeons.
Risk management for hospitalists.