Close Claim Study: Failure to assess and communicate

by Louise Walling and Laura Hale Brockway, ELS

A 65-year-old man was diagnosed with an 8-cm asymptomatic abdominal aortic aneurysm on December 14. He was admitted to a local hospital on December 17 for treatment. Although the patient had a history of chronic obstructive pulmonary disease, he had quit smoking four years earlier. His physician cleared him for surgery.

Physician action
On the morning of December 20, a vascular surgeon performed an endovascular repair of the abdominal aortic aneurysm. He and the assistant surgeon reviewed intraoperative angiograms to confirm placement of the stent. The surgery went as expected and the patient tolerated the procedure well.

A radiologist reviewed the intraoperative angiograms four hours after the surgery and noted that the endovascular stent graft was in place. He noted that the top of the stent graft was at level L-1, but commented that the renal arteries were “not well seen.” He recommended that the angiographic images be correlated with clinical history and the surgical findings. There was no communication from the radiologist to the vascular surgeon about the over-read of these films.

Six hours after the procedure, the patient began experiencing severe back and abdominal pain and had a sudden drop in urine output. The vascular surgeon was notified two hours later. He ordered a renal duplex scan that revealed no blood flow to the kidneys, no visualization of urine in the bladder, and no evidence of hydronephrosis. This was reported at approximately 2 a.m. on December 21.

At 11:30 a.m. on December 22, the vascular surgeon took the patient back to the OR for revision of the stent graft. During the procedure, the vascular surgeon documented the presence of an
occlusion of the renal arteries, so he moved the graft distally by 2 to 3 mm. A selective catheterization of the left renal artery was completed. Once good flow to the left renal artery was produced using an 8 x 15 stent, catheterization of the right renal artery was performed deploying a 6 x 15 stent. The final angiographic study showed patency of both renal arteries.

Postoperatively, the patient’s creatinine values worsened and he experienced decreased urine output. He required hemodialysis. The patient also developed pneumonia and was treated with IV antibiotics. He was discharged in stable condition on January 4, but lost function of both kidneys. He required renal dialysis for the remainder of his life.

Lawsuits were filed against the vascular surgeon and the radiologist. The allegations included:
• failure to properly, adequately, or timely assess the patient’s medical condition (vascular surgeon);
• failure to timely administer proper medical care (vascular surgeon);
• failure to properly interpret the intraoperative angiograms (vascular surgeon); and
• failure to immediately communicate findings from the overread of the angiograms (radiologist).

Legal implications
Physicians who reviewed this case for the plaintiffs and for the defense felt that the aortic stent graft was deployed in a position that blocked the renal arteries. The vascular surgeon testified
that he saw good blood flow to the renal arteries during the latter phase of the endovascular repair. Although he surmised that the aortic stent graft must have migrated, he was unable to find any published studies showing that a graft could migrate proximally.

The radiologist correctly identified the problem, but there was no record that he communicated these findings to the vascular surgeon. The vascular surgeon testified that he did not ask the
radiologist to report to him about the findings and he did not review the radiology report since he performed the procedure and saw the intraoperative angiograms. Further, the vascular surgeon testified that he would expect the nurses to report any postoperative symptoms such as back pain, flank pain, and lack of urine output immediately.

Risk management considerations
Communication issues are frequently a focus in malpractice suits and can be identified at various levels — physician to physician, staff to physician, or physician to patient. The vascular surgeon did not read the radiologist’s report or request communication from the radiologist. The radiologist did not orally report his findings to the surgeon. In conjunction with their specialty society guidelines, physicians would benefit from developing methods to prevent communication breakdowns.

The American College of Radiology has published guidelines that include a course of action to take when reviewing films that may require “non-routine communication.” “Routine reporting
of imaging findings is communicated through the usual