Claims Case Study: Abdominal Mass

The Case

The patient, a 58-year-old retired nurse, presented to the emergency department (ED) with abdominal pain, nausea, and vomiting. The first emergency physician conducted a physical exam and ordered blood work, a urinalysis, and a KUB (image of the kidneys, ureters, and bladder). The physician assessed that the patient’s abdomen was mild to moderately tender (there was no guarding or rebound tenderness) and interpreted the initial read of the KUB as normal. The patient was diagnosed with acute gastritis and a urinary tract infection. She was given an antibiotic prescription, instructed to follow-up with her primary care provider in two days, and discharged home.

Approximately two hours after the patient’s discharge, the radiologist (not named in this suit) dictated his final imaging report on the patient’s KUB. While he noted no evidence of an acute abdominal abnormality, he did point out a questionable density over the lower abdomen/pelvis. He said the possibility of an abdominal/pelvic mass could not be excluded, adding that clinical correlation and evaluation with either an ultrasound or a CT scan were recommended.

By this time, the first emergency medicine physician had left for the day, and our insured, the second emergency medicine physician, was now on duty. The radiologist contacted the second physician about his findings, and noted that exchange in the radiology . Per hospital policy, the radiology report was also auto-faxed to the patient’s listed primary care provider. This was also documented on the radiology report. The second emergency medicine physician did not contact the patient, and he did not direct any member of the ED staff to contact the patient about the KUB findings.

The patient did not follow up with her primary care provider as instructed in her discharge documentation. Six months after the patient’s ED visit, she presented to her primary care provider with a palpable mass in her abdomen. An abdominal CT scan revealed a 16-inch abdominal/pelvic mass. The patient was referred to a gynecologic oncologist and diagnosed with advanced ovarian cancer. She underwent a hysterectomy, an oophorectomy, and tumor debulking surgery. Although chemotherapy was initiated, the cancer had already metastasized to the patient’s brain, and she expired approximately 11 months after her initial ED visit.

During his deposition, the second physician testified that he had no recollection of speaking with the radiologist. The representatives of the hospital (also being sued in this matter) testified that the results of the KUB had been faxed to the patient’s primary care provider. However, further investigation revealed the hospital used an incorrect fax number for the patient’s primary care provider. The fax number utilized was not designated for the receipt of patient testing results, and there was no record of the report ever being received.

The patient’s estate alleged that the first physician failed to identify the mass during her initial read of the KUB and that she was negligent for discharging the patient before the final read by the radiologist. The allegation against the second physician was that he had a duty to make sure the patient was contacted by a member of the ED staff and informed of the mass after the radiologist reported the findings to him. The estate also alleged that the hospital system was negligent because it lacked comprehensive policies to ensure that patients were advised of abnormal lab/imaging results that were returned after discharge.

The radiologist in this matter was not named in the suit.  He clearly documented that he noted an abnormal finding and discussed it with the physician.  In addition, the report was marked as being faxed to the patient’s primary care provider.  In this case, even though the number utilized by the hospital was incorrect, the radiologist was felt to have met the standard of care in notifying other providers about an abnormal result that needed clinical correlation.

The case was settled prior to trial with contribution from both physicians and the hospital.

Risk Management Takeaways

It is essential to establish a process to report lab results and other important findings to patients who have already been discharged. Curi’s Risk Management department recommends doing the following:

• For ED providers, review systems and policies for reconciling all diagnostic test results prior to discharge. Establish safe systems and practices for any pending or outstanding tests, as well as required patient follow-up at the time of disposition from the ED.
• Review the current policy for advising patients of abnormal results and ensure the procedure includes steps for notifying patients post-discharge.
• For practices that receive patient reports from outside providers or testing facilities, put in place a quality assurance process receives and records results within the patient record.
• Build a process to alert the practice’s contacts about updated contact information with each technology upgrade.
• Make sure the practice’s communication system (fax or email) provides verification that information sent reached the recipient.

For further guidance, Curi members are encouraged to reach out to our Claims and Risk Management Departments at 800.662.7917.