Advanced Practice Provider Case Study: Failure to Diagnose

By: Janet McCrossen, BSN, RN
2 Minute Read

A 52-year-old woman went to a walk-in clinic complaining primarily of a headache and requested a physical exam. Unbeknownst to the physician assistant (PA) that was treating her, the patient had presented to the local emergency department with similar complaints two days earlier. A physician assistant performed the patient’s physical exam during this visit but did not identify the cause of her headaches.

During the exam, the patient said that she was also experiencing chest pain and GERD-like symptoms. In response, the PA ordered additional testing and medication and instructed the patient to return the following week. However, the patient did not return.

Approximately five weeks after this visit, the patient was taken urgently to the local hospital emergency department with a severe headache and was airlifted to the nearby tertiary care center. At the care center, she underwent surgery for a meningioma and died from a brain stem herniation.

What Went Wrong:

In this instance, the PA should have followed up on initial complaints to further investigate the cause of the patient’s symptoms. Unfortunately, documentation on the patient chart did not reflect that a full medical history was obtained, and the patient did not receive the proper testing in keeping with her symptoms. If she had received a full radiology study, the radiologist likely would have identified the meningioma, and surgical intervention could have given the patient a favorable outcome.

Key Takeaways:

  • PAs and other advanced practice providers (APPs) should always follow up on complaints noted by a patient in triage and continue to investigate symptoms.
  • Providers should ensure that treatment plans are carried out following a visit and document each interaction.
  • Follow-up testing ordered should also reflect the symptoms presented.
  • If a practice’s EMR platform does not contain specific fields for exam findings, treatment plans, and results, all of this information should still be documented in progress notes.



For further guidance on issues surrounding APPs, Curi members are encouraged to explore tools and resources included in our state-specific Advanced Practice Provider Toolkits. These toolkits are designed to answer questions related to scope of practice, onboarding, and supervision of APPs. Members may also reach out to one of our risk solutions experts at Curi Advisory by calling 800.622.7917.


Janet McCrossen, BSN, RN
Janet McCrossen is a Curi Risk Consultant, based in Philadelphia, PA.

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