Closed claim study: failure to report differential diagnosis, issuing a misleading report

The following closed claim study is based on a malpractice claim from TMLT.  This case illustrates how action or inaction on the part of physicians led to allegations of professional liability, and how risk management techniques may have either prevented the outcome or increased the physician’s defensibility. An attempt has been made to make the material less easy to identify. If you recognize your own case, please be assured it is presented solely to emphasize the issues of the case.

A 68-year-old man came to his family physician with complaints of a several month history of worsening memory, confusion, difficulty sleeping, and intermittent problems with his left hand and arm becoming weak and numb.

Physician action
The family physician suspected TIAs, but wanted to rule out brain cancer. He ordered a CT scan of the head and arranged for a carotid ultrasound. The family physician completed the order form for the CT, requesting the CT to rule out brain cancer, but noted possible TIAs. He also included the patient’s symptoms on the form, and asked that the patient’s medical records be forwarded to the testing facility.

The family physician’s nurse called the hospital to set up the CT scan. She later testified that she read the request from the family physician as “R/O brain cancer.” The billing clerk at the hospital changed that to read “R/O METS.” This information was then sent to the hospital’s radiology technician who changed it from “R/O METS” to “METS” because “R/O METS” did not fit the Medicare codes.

When the radiologist received the request, the clinical diagnosis was “METS.” None of the family physician’s suspicions or medical records noting “TIAs, organic brain syndrome, or mental status changes,” were forwarded to the radiologist. The CT scan was performed with and without enhancement. In the initial portion of the radiologist’s report, he noted that what he saw was “consistent with metastatic disease.” Later in his report, he made reference to “this metastasis” rather than “this possible metastasis.”

The day after the CT scan, the patient reported to the emergency department at another hospital. His symptoms included dizziness, weakness, memory loss and slurred speech. The ED physician suspected a TIA and administered heparin. The patient was then admitted to the hospital, under the care of an internal medicine physician. This physician continued the heparin, ordered a carotid ultrasound, and contacted the radiologist about the previous CT scan. The radiologist read the report to the internal medicine physician. At that time, the internal medicine physician decided to discontinue the patient’s anticoagulation treatment because it was contraindicated for patients with cancer. The carotid ultrasound was also cancelled.

The internal medicine physician ordered tests to look for the tumor, but the tests failed to find any evidence of cancer. After two days in the hospital, the patient was discharged with a diagnosis of “metastatic brain disease, primary tumor site undetermined,” and was referred to an oncologist.

Two weeks after he left the hospital, the patient suffered a major CVA. A CT scan and MRI of the head identified multiple areas of infarction with no evidence of metastatic tumor. A carotid flow study revealed total occlusion of the left internal carotid artery. The CVA caused severe paralysis to the left side of the body. Currently, the patient uses a wheelchair and is unable to speak.

A lawsuit was filed against the radiologist, alleging the following:

  • failure to report an appropriate, accurate differential diagnosis;
  • failure to suggest additional, follow-up radiological studies;
  • issuing a misleading and inaccurate CT report of metastasis; and
  • failure to clinically correlate the information in the CT report which ultimately led to a failure to diagnose the patient’s condition.

The family physician, the hospital where the CT scan occurred, and the internal medicine physician were also named in the lawsuit.

Legal implications
The defendant radiologist was adamant that his interpretation of the CT scan was correct and was consistent with the history provided to him on the radiology request. The statement “METS” led the radiologist to believe that a diagnosis of cerebral metastases had been established, and that he was to report whether brain metastases were present on the CT scan.

Two board certified radiologists reviewed this case and both felt the CT scan was far more suggestive of stroke than brain metastasis. Both radiologists said they would have listed possible ischemia on the differential. The plaintiff’s expert, also a board certified radiologist, felt the defendant’s read of the CT scan was accurate, but the defendant’s final impressions were incorrect because he did not list ischemic disease as a possible differential diagnosis.

The case against the radiologist was weakened by testimony from the co-defendant physicians and their experts. They all testified that it was within the standard of care to rely on the radiologist’s review of the CT in deciding to discontinue the patient’s anticoagulation treatment. This case was further complicated by two factors. There was a dispute between the family physician’s nurse and the hospital billing clerk over what information was relayed over the telephone about the request for the CT. Regardless of this dispute, the radiology technician changed the diagnosis from “R/O METS” to “METS” and this affected the defendant’s review of the CT.

The case against the radiologist was settled during trial. The hospital and family physician also settled. The case against the internal medicine physician was closed without indemnity payment.

Risk management considerations
The health care system broke down in many places in this case. What are the lessons to be learned? Physicians need a system to verify that their employees follow orders as directed. The patient’s symptoms and medical record information were not on the CT order. Additionally, billing clerks and radiology technicians should not be allowed to alter medical information.

Without the clinical history of possible TIAs, cognitive changes, and intermittent numbness of the left arm, the radiologist interpreted a CT scan assuming a diagnosis of metastasis. Including differential diagnoses and recommending further studies to rule out or confirm each diagnosis are standard protocols in the practice of radiology. Why was the carotid ultrasound not done? Apparently, it was not ordered at the same time as the CT scan. The nurse did not complete the orders and the family physician did not determine the oversight.