Jeffrey L. Susman, MD

Delayed referral ends in (too) late diagnosis of colon cancer

CONSTIPATION AND ABDOMINAL PAIN prompted a 45-year-old woman to consult her primary care physician, who recommended a change in diet. Two months later, the patient returned to the doctor because her symptoms hadn’t resolved, but admitted that she hadn’t altered her diet. The doctor repeated her recommendation for dietary change.

A month later, when the symptoms had worsened, the physician referred the woman to a gastroenterologist, who performed a colonoscopy. The colonoscopy revealed a large mass in the colon, which was diagnosed as stage IV cancer. The woman ultimately died.

PLAINTIFF’S CLAIM The doctor was negligent in failing to diagnose the cancer promptly.

THE DEFENSE The patient was treated for the complaints she presented with at each visit, and a referral wasn’t warranted until it was given.

VERDICT $420,000 New York verdict.

COMMENT I shudder when I read cases that could reflect my own practice patterns. How many patients with abdominal pain do we temporize? And the delay in diagnosis was only a few months!

Student in “excellent” health collapses on basketball court

The summer before he was to start college, an 18-year-old student went to an internist for a physical exam and asked the physician to complete a form that the college required. The physician documented a “slight systolic murmur” on the form, followed by a question mark. The physical was otherwise unremarkable, and the physician signed the form, indicating that the young man was in “excellent” health and fit to participate in all college activities without restrictions.

Nearly 4 years later, the student—then a senior and a member of the college basketball team—collapsed and died during a game. The cause of death: sudden cardiac death related to hypertrophic cardiomyopathy (HCM).

PLAINTIFF’S CLAIM The physician found a slight systolic murmur—a condition often associated with HCM—that should have prompted her to order further tests. Additional testing would have resulted in an HCM diagnosis.

THE DEFENSE The doctor did order an electrocardiogram, but the patient failed to keep the appointment. During the 3½ years after the exam, 5 other health care providers cleared the young man for college athletics.

VERDICT $1.6 million Massachusetts jury award.

COMMENT Sometimes seemingly innocuous findings can signify serious problems. Lack of closing the loop on documentation and follow-up remains a common denominator in malpractice settlements.

Sources: MoreLaw Lexapedia. Available at: http://www.morelaw.com/verdicts/case.asp?n=&s=MA&d=43384. Accessed May 11, 2010; Hypertrophic Cardiomyopathy Association correspondence.

Abnormal EKG with no follow-up, concludes with fatal MI

A 53-YEAR-OLD MAN WITH A HISTORY OF HEART DISEASE and cardiac symptoms went to his family physician of many years for a physical examination. The physician performed an electrocardiogram (EKG), which was normal, but the patient reported occasional chest pain. His physician referred him to a cardiologist for further evaluation. The cardiologist performed a stress test, which was normal.

Three years later, the patient had another physical exam and EKG. Although he reported no chest pain at this exam, he did mention heart palpitations, flutters, and skips. A computer reading revealed that the EKG was abnormal, with a possible inferior infarction. The patient’s physician nevertheless decided against a further work-up and did not refer him to a cardiologist.

Less than a month later, the man’s wife found him dead in bed. The death certificate cited myocardial infarction as the cause of death.

PLAINTIFF’S CLAIM No information about the plaintiff’s claim is available.

THE DEFENSE No information about the defense is available.

VERDICT $900,000 Virginia settlement.

COMMENT When faced with evidence of cardiac ischemia, prompt attention is indicated. Enough said.

Suicide attempt blamed on improper med management

A MAN WITH OBSESSIVE-COMPULSIVE DISORDER was prescribed fluoxetine by his psychiatrist as part of treatment. After several years, the psychiatrist discontinued the medication; the patient subsequently developed selective serotonin reuptake inhibitor (SSRI) discontinuation syndrome, including depression and suicidal ideation. The patient tried, unsuccessfully, to kill himself with a shotgun and ended up facing criminal charges of reckless endangerment.

The patient was transferred to the care of another psychiatrist, who prescribed higher doses of fluoxetine. The suicidal ideation stopped, but the patient complained of ongoing, disabling depression and distress related to his suicide attempt.

PLAINTIFF’S CLAIM The doctor failed to manage the patient’s medication properly. Discontinuing fluoxetine is known to cause the symptoms the patient experienced.

THE DEFENSE The plaintiff had told the first psychiatrist that he wanted to discontinue fluoxetine and had failed to report any concerns related to stopping the drug. SSRI discontinuation syndrome is rare, and the symptoms are difficult to detect.

VERDICT $911,000 New York verdict.

COMMENT Although I would quibble with the label discontinuation syndrome (sounds more like recurrent major depressive disorder), it’s very important to monitor patients carefully when starting treatment with an antidepressant, during changes in therapy, and after discontinuing a drug.

Delayed referral ends in (too) late diagnosis of colon cancer

CONSTIPATION AND ABDOMINAL PAIN prompted a 45-year-old woman to consult her primary care physician, who recommended a change in diet. Two months later, the patient returned to the doctor because her symptoms hadn’t resolved, but admitted that she hadn’t altered her diet. The doctor repeated her recommendation for dietary change.

A month later, when the symptoms had worsened, the physician referred the woman to a gastroenterologist, who performed a colonoscopy. The colonoscopy revealed a large mass in the colon, which was diagnosed as stage IV cancer. The woman ultimately died.

PLAINTIFF’S CLAIM The doctor was negligent in failing to diagnose the cancer promptly.

THE DEFENSE The patient was treated for the complaints she presented with at each visit, and a referral wasn’t warranted until it was given.

VERDICT $420,000 New York verdict.

COMMENT I shudder when I read cases that could reflect my own practice patterns. How many patients with abdominal pain do we temporize? And the delay in diagnosis was only a few months!

Student in “excellent” health collapses on basketball court

The summer before he was to start college, an 18-year-old student went to an internist for a physical exam and asked the physician to complete a form that the college required. The physician documented a “slight systolic murmur” on the form, followed by a question mark. The physical was otherwise unremarkable, and the physician signed the form, indicating that the young man was in “excellent” health and fit to participate in all college activities without restrictions.

Nearly 4 years later, the student—then a senior and a member of the college basketball team—collapsed and died during a game. The cause of death: sudden cardiac death related to hypertrophic cardiomyopathy (HCM).

PLAINTIFF’S CLAIM The physician found a slight systolic murmur—a condition often associated with HCM—that should have prompted her to order further tests. Additional testing would have resulted in an HCM diagnosis.

THE DEFENSE The doctor did order an electrocardiogram, but the patient failed to keep the appointment. During the 3½ years after the exam, 5 other health care providers cleared the young man for college athletics.

VERDICT $1.6 million Massachusetts jury award.

COMMENT Sometimes seemingly innocuous findings can signify serious problems. Lack of closing the loop on documentation and follow-up remains a common denominator in malpractice settlements.

Sources: MoreLaw Lexapedia. Available at: http://www.morelaw.com/verdicts/case.asp?n=&s=MA&d=43384. Accessed May 11, 2010; Hypertrophic Cardiomyopathy Association correspondence.

Abnormal EKG with no follow-up, concludes with fatal MI

A 53-YEAR-OLD MAN WITH A HISTORY OF HEART DISEASE and cardiac symptoms went to his family physician of many years for a physical examination. The physician performed an electrocardiogram (EKG), which was normal, but the patient reported occasional chest pain. His physician referred him to a cardiologist for further evaluation. The cardiologist performed a stress test, which was normal.

Three years later, the patient had another physical exam and EKG. Although he reported no chest pain at this exam, he did mention heart palpitations, flutters, and skips. A computer reading revealed that the EKG was abnormal, with a possible inferior infarction. The patient’s physician nevertheless decided against a further work-up and did not refer him to a cardiologist.

Less than a month later, the man’s wife found him dead in bed. The death certificate cited myocardial infarction as the cause of death.

PLAINTIFF’S CLAIM No information about the plaintiff’s claim is available.

THE DEFENSE No information about the defense is available.

VERDICT $900,000 Virginia settlement.

COMMENT When faced with evidence of cardiac ischemia, prompt attention is indicated. Enough said.

Suicide attempt blamed on improper med management

A MAN WITH OBSESSIVE-COMPULSIVE DISORDER was prescribed fluoxetine by his psychiatrist as part of treatment. After several years, the psychiatrist discontinued the medication; the patient subsequently developed selective serotonin reuptake inhibitor (SSRI) discontinuation syndrome, including depression and suicidal ideation. The patient tried, unsuccessfully, to kill himself with a shotgun and ended up facing criminal charges of reckless endangerment.

The patient was transferred to the care of another psychiatrist, who prescribed higher doses of fluoxetine. The suicidal ideation stopped, but the patient complained of ongoing, disabling depression and distress related to his suicide attempt.

PLAINTIFF’S CLAIM The doctor failed to manage the patient’s medication properly. Discontinuing fluoxetine is known to cause the symptoms the patient experienced.

THE DEFENSE The plaintiff had told the first psychiatrist that he wanted to discontinue fluoxetine and had failed to report any concerns related to stopping the drug. SSRI discontinuation syndrome is rare, and the symptoms are difficult to detect.

VERDICT $911,000 New York verdict.

COMMENT Although I would quibble with the label discontinuation syndrome (sounds more like recurrent major depressive disorder), it’s very important to monitor patients carefully when starting treatment with an antidepressant, during changes in therapy, and after discontinuing a drug.

Delayed referral ends in (too) late diagnosis of colon cancer

CONSTIPATION AND ABDOMINAL PAIN prompted a 45-year-old woman to consult her primary care physician, who recommended a change in diet. Two months later, the patient returned to the doctor because her symptoms hadn’t resolved, but admitted that she hadn’t altered her diet. The doctor repeated her recommendation for dietary change.

A month later, when the symptoms had worsened, the physician referred the woman to a gastroenterologist, who performed a colonoscopy. The colonoscopy revealed a large mass in the colon, which was diagnosed as stage IV cancer. The woman ultimately died.

PLAINTIFF’S CLAIM The doctor was negligent in failing to diagnose the cancer promptly.

THE DEFENSE The patient was treated for the complaints she presented with at each visit, and a referral wasn’t warranted until it was given.

VERDICT $420,000 New York verdict.

COMMENT I shudder when I read cases that could reflect my own practice patterns. How many patients with abdominal pain do we temporize? And the delay in diagnosis was only a few months!

Student in “excellent” health collapses on basketball court

The summer before he was to start college, an 18-year-old student went to an internist for a physical exam and asked the physician to complete a form that the college required. The physician documented a “slight systolic murmur” on the form, followed by a question mark. The physical was otherwise unremarkable, and the physician signed the form, indicating that the young man was in “excellent” health and fit to participate in all college activities without restrictions.

Nearly 4 years later, the student—then a senior and a member of the college basketball team—collapsed and died during a game. The cause of death: sudden cardiac death related to hypertrophic cardiomyopathy (HCM).

PLAINTIFF’S CLAIM The physician found a slight systolic murmur—a condition often associated with HCM—that should have prompted her to order further tests. Additional testing would have resulted in an HCM diagnosis.

THE DEFENSE The doctor did order an electrocardiogram, but the patient failed to keep the appointment. During the 3½ years after the exam, 5 other health care providers cleared the young man for college athletics.

VERDICT $1.6 million Massachusetts jury award.

COMMENT Sometimes seemingly innocuous findings can signify serious problems. Lack of closing the loop on documentation and follow-up remains a common denominator in malpractice settlements.

Sources: MoreLaw Lexapedia. Available at: http://www.morelaw.com/verdicts/case.asp?n=&s=MA&d=43384. Accessed May 11, 2010; Hypertrophic Cardiomyopathy Association correspondence.

Abnormal EKG with no follow-up, concludes with fatal MI

A 53-YEAR-OLD MAN WITH A HISTORY OF HEART DISEASE and cardiac symptoms went to his family physician of many years for a physical examination. The physician performed an electrocardiogram (EKG), which was normal, but the patient reported occasional chest pain. His physician referred him to a cardiologist for further evaluation. The cardiologist performed a stress test, which was normal.

Three years later, the patient had another physical exam and EKG. Although he reported no chest pain at this exam, he did mention heart palpitations, flutters, and skips. A computer reading revealed that the EKG was abnormal, with a possible inferior infarction. The patient’s physician nevertheless decided against a further work-up and did not refer him to a cardiologist.

Less than a month later, the man’s wife found him dead in bed. The death certificate cited myocardial infarction as the cause of death.

PLAINTIFF’S CLAIM No information about the plaintiff’s claim is available.

THE DEFENSE No information about the defense is available.

VERDICT $900,000 Virginia settlement.

COMMENT When faced with evidence of cardiac ischemia, prompt attention is indicated. Enough said.

Suicide attempt blamed on improper med management

A MAN WITH OBSESSIVE-COMPULSIVE DISORDER was prescribed fluoxetine by his psychiatrist as part of treatment. After several years, the psychiatrist discontinued the medication; the patient subsequently developed selective serotonin reuptake inhibitor (SSRI) discontinuation syndrome, including depression and suicidal ideation. The patient tried, unsuccessfully, to kill himself with a shotgun and ended up facing criminal charges of reckless endangerment.

The patient was transferred to the care of another psychiatrist, who prescribed higher doses of fluoxetine. The suicidal ideation stopped, but the patient complained of ongoing, disabling depression and distress related to his suicide attempt.

PLAINTIFF’S CLAIM The doctor failed to manage the patient’s medication properly. Discontinuing fluoxetine is known to cause the symptoms the patient experienced.

THE DEFENSE The plaintiff had told the first psychiatrist that he wanted to discontinue fluoxetine and had failed to report any concerns related to stopping the drug. SSRI discontinuation syndrome is rare, and the symptoms are difficult to detect.

VERDICT $911,000 New York verdict.

COMMENT Although I would quibble with the label discontinuation syndrome (sounds more like recurrent major depressive disorder), it’s very important to monitor patients carefully when starting treatment with an antidepressant, during changes in therapy, and after discontinuing a drug.

Delay in diagnosing blastomycosis cuts a young life short

COUGH, FEVER, AND FLU-LIKE SYMPTOMS for a week prompted a 25-year-old man to visit his physician, who prescribed an antibiotic. When the symptoms didn‘t improve after 3 days, the patient went to a local health care group, where a physician assistant continued the antibiotic, performed a tuberculosis test, and instructed the young man to return in 3 days.

At the return visit, the patient still had the cough and a fever of 101°F, as well as decreased breath sounds and bilateral pain in his lower lungs when reclining. Another physician assistant diagnosed pneumonia and prescribed a different antibiotic, but didn’t order chest radiographs or blood work—or measure oxygen saturation. He wrote the patient a 5-day excuse from work and told him to return if his condition worsened.

A few days later, the patient went to the emergency department, where he was diagnosed with a pulmonary blastomycosis infection. The infection was too far advanced to treat effectively, and the man died shortly thereafter.

PLAINTIFF’S CLAIM The physician assistants were negligent for not having radiographs or blood work done and not consulting the supervising physician. The supervising physician didn’t review the examination and treatment notes.

THE DEFENSE No negligence occurred; an earlier diagnosis wouldn’t have changed the outcome.

VERDICT $3.7 million Wisconsin verdict.

COMMENT This case sends shivers down my spine. I really get worried when huge verdicts are returned for failure to diagnose rare conditions. How many times a week do we treat patients for “bronchitis” or community-acquired pneumonia without getting a radiograph or oxygen saturation measurement—especially in a 25-year-old!

A drug overdose, with plenty of blame to go around

AN 85-YEAR-OLD WOMAN was admitted to a nursing home for a temporary stay after she broke her arm shoveling snow in her driveway. Her physician prescribed a medication, to be given once a week, for the woman’s rheumatoid arthritis. But because a nurse transcribed the order incorrectly, the patient was given the medication every day. After 17 days, she died of an overdose.

PLAINTIFF’S CLAIM The nurse was negligent in transcribing the order incorrectly, the doctor was negligent for signing the order without reading the nurse’s note, and the pharmacy was negligent for failing to discover the dosage error.

THE DEFENSE No information about the defense is available.

VERDICT $1 million Ohio settlement.

COMMENT The moral of this story: Don’t sign those nursing home orders on autopilot!

Unexamined mass isn’t benign after all

A PEA-SIZED MASS on a 34-year-old woman’s head was diagnosed as a sebaceous cyst. A physician assistant removed the mass, which was thrown away without being sent for pathologic examination. A year later, the mass reappeared and was identified as a sarcoma. The woman died a year later.

PLAINTIFF’S CLAIM The doctor and physician assistant were negligent in failing to diagnose the mass accurately and failing to send it for pathologic analysis.

THE DEFENSE The mass appeared normal and didn’t require examination.

VERDICT $1.5 million Texas settlement.

COMMENT I make it a policy to send all skin specimens—no matter how innocuous—for pathologic determination. I recently testified for a defendant in a case similar to this one (fortunately the physician won).

Delay in diagnosing blastomycosis cuts a young life short

COUGH, FEVER, AND FLU-LIKE SYMPTOMS for a week prompted a 25-year-old man to visit his physician, who prescribed an antibiotic. When the symptoms didn‘t improve after 3 days, the patient went to a local health care group, where a physician assistant continued the antibiotic, performed a tuberculosis test, and instructed the young man to return in 3 days.

At the return visit, the patient still had the cough and a fever of 101°F, as well as decreased breath sounds and bilateral pain in his lower lungs when reclining. Another physician assistant diagnosed pneumonia and prescribed a different antibiotic, but didn’t order chest radiographs or blood work—or measure oxygen saturation. He wrote the patient a 5-day excuse from work and told him to return if his condition worsened.

A few days later, the patient went to the emergency department, where he was diagnosed with a pulmonary blastomycosis infection. The infection was too far advanced to treat effectively, and the man died shortly thereafter.

PLAINTIFF’S CLAIM The physician assistants were negligent for not having radiographs or blood work done and not consulting the supervising physician. The supervising physician didn’t review the examination and treatment notes.

THE DEFENSE No negligence occurred; an earlier diagnosis wouldn’t have changed the outcome.

VERDICT $3.7 million Wisconsin verdict.

COMMENT This case sends shivers down my spine. I really get worried when huge verdicts are returned for failure to diagnose rare conditions. How many times a week do we treat patients for “bronchitis” or community-acquired pneumonia without getting a radiograph or oxygen saturation measurement—especially in a 25-year-old!

A drug overdose, with plenty of blame to go around

AN 85-YEAR-OLD WOMAN was admitted to a nursing home for a temporary stay after she broke her arm shoveling snow in her driveway. Her physician prescribed a medication, to be given once a week, for the woman’s rheumatoid arthritis. But because a nurse transcribed the order incorrectly, the patient was given the medication every day. After 17 days, she died of an overdose.

PLAINTIFF’S CLAIM The nurse was negligent in transcribing the order incorrectly, the doctor was negligent for signing the order without reading the nurse’s note, and the pharmacy was negligent for failing to discover the dosage error.

THE DEFENSE No information about the defense is available.

VERDICT $1 million Ohio settlement.

COMMENT The moral of this story: Don’t sign those nursing home orders on autopilot!

Unexamined mass isn’t benign after all

A PEA-SIZED MASS on a 34-year-old woman’s head was diagnosed as a sebaceous cyst. A physician assistant removed the mass, which was thrown away without being sent for pathologic examination. A year later, the mass reappeared and was identified as a sarcoma. The woman died a year later.

PLAINTIFF’S CLAIM The doctor and physician assistant were negligent in failing to diagnose the mass accurately and failing to send it for pathologic analysis.

THE DEFENSE The mass appeared normal and didn’t require examination.

VERDICT $1.5 million Texas settlement.

COMMENT I make it a policy to send all skin specimens—no matter how innocuous—for pathologic determination. I recently testified for a defendant in a case similar to this one (fortunately the physician won).

Delay in diagnosing blastomycosis cuts a young life short

COUGH, FEVER, AND FLU-LIKE SYMPTOMS for a week prompted a 25-year-old man to visit his physician, who prescribed an antibiotic. When the symptoms didn‘t improve after 3 days, the patient went to a local health care group, where a physician assistant continued the antibiotic, performed a tuberculosis test, and instructed the young man to return in 3 days.

At the return visit, the patient still had the cough and a fever of 101°F, as well as decreased breath sounds and bilateral pain in his lower lungs when reclining. Another physician assistant diagnosed pneumonia and prescribed a different antibiotic, but didn’t order chest radiographs or blood work—or measure oxygen saturation. He wrote the patient a 5-day excuse from work and told him to return if his condition worsened.

A few days later, the patient went to the emergency department, where he was diagnosed with a pulmonary blastomycosis infection. The infection was too far advanced to treat effectively, and the man died shortly thereafter.

PLAINTIFF’S CLAIM The physician assistants were negligent for not having radiographs or blood work done and not consulting the supervising physician. The supervising physician didn’t review the examination and treatment notes.

THE DEFENSE No negligence occurred; an earlier diagnosis wouldn’t have changed the outcome.

VERDICT $3.7 million Wisconsin verdict.

COMMENT This case sends shivers down my spine. I really get worried when huge verdicts are returned for failure to diagnose rare conditions. How many times a week do we treat patients for “bronchitis” or community-acquired pneumonia without getting a radiograph or oxygen saturation measurement—especially in a 25-year-old!

A drug overdose, with plenty of blame to go around

AN 85-YEAR-OLD WOMAN was admitted to a nursing home for a temporary stay after she broke her arm shoveling snow in her driveway. Her physician prescribed a medication, to be given once a week, for the woman’s rheumatoid arthritis. But because a nurse transcribed the order incorrectly, the patient was given the medication every day. After 17 days, she died of an overdose.

PLAINTIFF’S CLAIM The nurse was negligent in transcribing the order incorrectly, the doctor was negligent for signing the order without reading the nurse’s note, and the pharmacy was negligent for failing to discover the dosage error.

THE DEFENSE No information about the defense is available.

VERDICT $1 million Ohio settlement.

COMMENT The moral of this story: Don’t sign those nursing home orders on autopilot!

Unexamined mass isn’t benign after all

A PEA-SIZED MASS on a 34-year-old woman’s head was diagnosed as a sebaceous cyst. A physician assistant removed the mass, which was thrown away without being sent for pathologic examination. A year later, the mass reappeared and was identified as a sarcoma. The woman died a year later.

PLAINTIFF’S CLAIM The doctor and physician assistant were negligent in failing to diagnose the mass accurately and failing to send it for pathologic analysis.

THE DEFENSE The mass appeared normal and didn’t require examination.

VERDICT $1.5 million Texas settlement.

COMMENT I make it a policy to send all skin specimens—no matter how innocuous—for pathologic determination. I recently testified for a defendant in a case similar to this one (fortunately the physician won).

Improperly treated C difficile leads to total colectomy

A 66-YEAR-OLD MAN contracted Clostridium difficile during hospitalization for treatment of a foot infection. The treating physician prescribed a 7-day course of antibiotics rather than the 14-day course recommended by a hospital infectious disease specialist. On the day the patient was discharged from the hospital, the treating physician dictated a letter to the patient’s primary care physician, but misdated it with the previous year.

When the patient visited his primary care physician the following week, he was seen by an associate of his regular doctor. According to the patient, the associate said she hadn’t seen the letter that had been sent to his primary care physician. The associate then re-prescribed the cephalosporin antibiotic that had led to the patient’s C difficile illness in the first place.

When the patient went back to his primary care physician’s office 2 weeks later, a physician assistant (PA) told him to return to the hospital because he’d been ill since discharge. At the hospital, toxic megacolon and septicemia were diagnosed, and the patient underwent immediate surgery to remove his entire colon and perform an ileostomy.

PLAINTIFF’S CLAIM The doctor who treated the foot infection at the hospital was negligent in failing to follow up and properly transfer care of the patient to the primary care physician. The primary care physician and his associate were negligent in failing to treat the C difficile infection properly.

THE DEFENSE The doctor who treated the foot infection denied negligence and maintained that he’d acted properly in dictating the discharge letter to the primary care physician.

The primary care physician and his associate claimed that they hadn’t received the letter until more than 30 days after the patient was discharged. The plaintiff countered that the PA had told him he had cellulitis and osteomyelitis—something the PA couldn’t have known unless he’d seen the letter describing those diagnoses. The plaintiff also contended that neither the primary care physician nor his associate complained about the tardiness of the letter at the time they received it.

VERDICT $2.75 million Pennsylvania verdict.

COMMENT This case is a classic failure of our system for coordination and handoff of care. Although such problems are endemic, substantial malpractice judgments await the unwary.

For want of a timely transfusion, man bleeds to death

A MAN SUSPECTED OF HAVING GASTROINTESTINAL BLEEDING was admitted to a university medical center. He collapsed the next day. A resident informed the attending physician, who ordered a transfusion over the phone. The patient died of cardiac arrest from internal bleeding 6 hours after the transfusion was ordered, but before it was given.

PLAINTIFF’S CLAIM The blood bank had reported that the transfusion was ready 3 hours before the man collapsed; the attending physician, resident, and nurses were negligent in failing to administer the transfusion in a timely manner.

THE DEFENSE The attending physician claimed that he wasn’t required to come to the hospital for 24 hours after the patient was admitted and that the resident didn’t provide him with information that would have prompted him to come in and examine the patient. The resident maintained that he gave the attending physician all the necessary data and provided an accurate account of what had happened to the patient.

VERDICT $1.75 million New Jersey settlement.

COMMENT Speaking of coordination of care, understand the risks of working with residents, particularly when caring for a potentially unstable patient. I doubt many juries would be sympathetic to, “I wasn’t required to come to the hospital for 24 hours after admission.”

Improperly treated C difficile leads to total colectomy

A 66-YEAR-OLD MAN contracted Clostridium difficile during hospitalization for treatment of a foot infection. The treating physician prescribed a 7-day course of antibiotics rather than the 14-day course recommended by a hospital infectious disease specialist. On the day the patient was discharged from the hospital, the treating physician dictated a letter to the patient’s primary care physician, but misdated it with the previous year.

When the patient visited his primary care physician the following week, he was seen by an associate of his regular doctor. According to the patient, the associate said she hadn’t seen the letter that had been sent to his primary care physician. The associate then re-prescribed the cephalosporin antibiotic that had led to the patient’s C difficile illness in the first place.

When the patient went back to his primary care physician’s office 2 weeks later, a physician assistant (PA) told him to return to the hospital because he’d been ill since discharge. At the hospital, toxic megacolon and septicemia were diagnosed, and the patient underwent immediate surgery to remove his entire colon and perform an ileostomy.

PLAINTIFF’S CLAIM The doctor who treated the foot infection at the hospital was negligent in failing to follow up and properly transfer care of the patient to the primary care physician. The primary care physician and his associate were negligent in failing to treat the C difficile infection properly.

THE DEFENSE The doctor who treated the foot infection denied negligence and maintained that he’d acted properly in dictating the discharge letter to the primary care physician.

The primary care physician and his associate claimed that they hadn’t received the letter until more than 30 days after the patient was discharged. The plaintiff countered that the PA had told him he had cellulitis and osteomyelitis—something the PA couldn’t have known unless he’d seen the letter describing those diagnoses. The plaintiff also contended that neither the primary care physician nor his associate complained about the tardiness of the letter at the time they received it.

VERDICT $2.75 million Pennsylvania verdict.

COMMENT This case is a classic failure of our system for coordination and handoff of care. Although such problems are endemic, substantial malpractice judgments await the unwary.

For want of a timely transfusion, man bleeds to death

A MAN SUSPECTED OF HAVING GASTROINTESTINAL BLEEDING was admitted to a university medical center. He collapsed the next day. A resident informed the attending physician, who ordered a transfusion over the phone. The patient died of cardiac arrest from internal bleeding 6 hours after the transfusion was ordered, but before it was given.

PLAINTIFF’S CLAIM The blood bank had reported that the transfusion was ready 3 hours before the man collapsed; the attending physician, resident, and nurses were negligent in failing to administer the transfusion in a timely manner.

THE DEFENSE The attending physician claimed that he wasn’t required to come to the hospital for 24 hours after the patient was admitted and that the resident didn’t provide him with information that would have prompted him to come in and examine the patient. The resident maintained that he gave the attending physician all the necessary data and provided an accurate account of what had happened to the patient.

VERDICT $1.75 million New Jersey settlement.

COMMENT Speaking of coordination of care, understand the risks of working with residents, particularly when caring for a potentially unstable patient. I doubt many juries would be sympathetic to, “I wasn’t required to come to the hospital for 24 hours after admission.”

Improperly treated C difficile leads to total colectomy

A 66-YEAR-OLD MAN contracted Clostridium difficile during hospitalization for treatment of a foot infection. The treating physician prescribed a 7-day course of antibiotics rather than the 14-day course recommended by a hospital infectious disease specialist. On the day the patient was discharged from the hospital, the treating physician dictated a letter to the patient’s primary care physician, but misdated it with the previous year.

When the patient visited his primary care physician the following week, he was seen by an associate of his regular doctor. According to the patient, the associate said she hadn’t seen the letter that had been sent to his primary care physician. The associate then re-prescribed the cephalosporin antibiotic that had led to the patient’s C difficile illness in the first place.

When the patient went back to his primary care physician’s office 2 weeks later, a physician assistant (PA) told him to return to the hospital because he’d been ill since discharge. At the hospital, toxic megacolon and septicemia were diagnosed, and the patient underwent immediate surgery to remove his entire colon and perform an ileostomy.

PLAINTIFF’S CLAIM The doctor who treated the foot infection at the hospital was negligent in failing to follow up and properly transfer care of the patient to the primary care physician. The primary care physician and his associate were negligent in failing to treat the C difficile infection properly.

THE DEFENSE The doctor who treated the foot infection denied negligence and maintained that he’d acted properly in dictating the discharge letter to the primary care physician.

The primary care physician and his associate claimed that they hadn’t received the letter until more than 30 days after the patient was discharged. The plaintiff countered that the PA had told him he had cellulitis and osteomyelitis—something the PA couldn’t have known unless he’d seen the letter describing those diagnoses. The plaintiff also contended that neither the primary care physician nor his associate complained about the tardiness of the letter at the time they received it.

VERDICT $2.75 million Pennsylvania verdict.

COMMENT This case is a classic failure of our system for coordination and handoff of care. Although such problems are endemic, substantial malpractice judgments await the unwary.

For want of a timely transfusion, man bleeds to death

A MAN SUSPECTED OF HAVING GASTROINTESTINAL BLEEDING was admitted to a university medical center. He collapsed the next day. A resident informed the attending physician, who ordered a transfusion over the phone. The patient died of cardiac arrest from internal bleeding 6 hours after the transfusion was ordered, but before it was given.

PLAINTIFF’S CLAIM The blood bank had reported that the transfusion was ready 3 hours before the man collapsed; the attending physician, resident, and nurses were negligent in failing to administer the transfusion in a timely manner.

THE DEFENSE The attending physician claimed that he wasn’t required to come to the hospital for 24 hours after the patient was admitted and that the resident didn’t provide him with information that would have prompted him to come in and examine the patient. The resident maintained that he gave the attending physician all the necessary data and provided an accurate account of what had happened to the patient.

VERDICT $1.75 million New Jersey settlement.

COMMENT Speaking of coordination of care, understand the risks of working with residents, particularly when caring for a potentially unstable patient. I doubt many juries would be sympathetic to, “I wasn’t required to come to the hospital for 24 hours after admission.”

Follow-up foul-up leads to metastatic disease

A PRECANCEROUS POLYP was found in the stomach of a 50-year-old man during diagnostic gastroscopy. The pathologist’s report noted that an adjacent or underlying malignant process could not be ruled out and recommended additional tissue sampling. Upon reading the report, the gastroenterologist who had performed the gastroscopy wrote that another biopsy should be done within a few months.

The patient was seen subsequently by his primary care physician, whose office note mentioned the precancerous biopsy findings and indicated that another biopsy was necessary; the physician also wrote that malignancy in the stomach would have to be ruled out eventually. The doctor’s plan called for a repeat gastroscopy to reevaluate the dysplastic polyp. However, neither the primary care physician nor the gastroenterologist took additional steps to order, perform, or refer the patient for a follow-up endoscopy and biopsy of the lesion.

Three years later, the patient developed difficulty swallowing and lost weight rapidly. Diagnostic testing revealed a malignant tumor, at the same location as the polyp, and malignant-appearing lymph nodes.

The patient received a feeding jejunostomy tube and underwent concomitant radiation and chemotherapy. Surgery was planned, but the disease metastasized and was deemed inoperable. Despite additional treatment, the patient died at age 54.

PLAINTIFF’S CLAIM No information about the plaintiff’s claim is available.

DOCTORS’ DEFENSE The primary care physician argued that both he and the gastroenterologist were responsible for making sure the follow-up was done; the gastroenterologist claimed that the primary care physician was solely responsible for follow-up testing.

VERDICT $1.5 million Massachusetts settlement.

COMMENT Poor coordination of care and follow-up of results is a common source of malpractice actions. Keep a paper or electronic “tickler file” for important follow-up issues.

Unaddressed cardiovascular risks prove fatal

A 46-YEAR-OLD MAN went to the hospital, where he was seen by a family practitioner. The physician noted that the patient had a history of smoking, high cholesterol, and thyroid problems.

Early the following month, the patient died of cardiopulmonary arrest. Autopsy results showed arteriosclerotic disease, acute dissection of the coronary plaques, and left ventricular hypertrophy.

PLAINTIFF’S CLAIM The family practitioner failed to take a careful history and prescribe aspirin therapy and cholesterol-lowering medication. The patient should have been referred for a cardiac work-up.

DOCTOR’S DEFENSE The patient was advised of the importance of treatment to correct his condition.

VERDICT $575,000 Michigan settlement.

COMMENT I’m seeing a great increase in cases involving failure to address cardiovascular risk factors. Be sure to thoroughly document refusal of interventions or nonadherence.

Lack of surveillance delays lung cancer diagnosis

A 64-YEAR-OLD MAN was referred to a pulmonary specialist in January by his primary care physician after a computed tomography (CT) scan showed a spiculated density adjacent to the right main-stem bronchus and a prominent right hilar lymph node. The CT scan also revealed a noncalcified nodule in the right middle lobe.

Before examining the patient, the pulmonary specialist ordered a positron emission tomography (PET) scan, which he interpreted as showing no significant uptake and considered negative. He attributed the prominent lymph node to bronchitis and ordered surveillance at 3-month intervals.

A CT scan in May showed no change, but the radiologist noted that “the possibility of malignancy cannot be excluded.” When the patient saw the specialist in early June, the doctor recommended another CT scan in 3 months.

The patient did not return to the specialist until September of the following year. By that time, a CT scan taken a couple of months before (June) as part of preoperative clearance for knee surgery showed that the irregular mass had grown significantly since the CT scan in May of the previous year. A bronchoscopy done in September to evaluate the mass was negative. In November, however, a lymph node biopsy revealed that the patient had metastatic lung cancer. He died about a month later.

PLAINTIFF’S CLAIM Because the patient had a history of smoking and the CT scan revealed a density, the suspicion for cancer should have been high despite a negative PET scan. A specimen should have been obtained by thoracoscopy or thoracotomy to rule out cancer.

THE DEFENSE The pulmonary specialist followed the correct protocol; failure to diagnose cancer at the September visit didn’t affect the outcome because the cancer was already metastatic and incurable. The patient didn’t quit smoking or follow up regularly with his primary care physician. Moreover, the cancer was at least stage IIA when the primary care physician referred the patient to the specialist.

VERDICT Pennsylvania defense verdict.

COMMENT Although a defense verdict was ultimately returned, wouldn’t a “tickler file” or a reminder to the patient (and documentation if the patient failed to follow up as recommended) have been easier?

Follow-up foul-up leads to metastatic disease

A PRECANCEROUS POLYP was found in the stomach of a 50-year-old man during diagnostic gastroscopy. The pathologist’s report noted that an adjacent or underlying malignant process could not be ruled out and recommended additional tissue sampling. Upon reading the report, the gastroenterologist who had performed the gastroscopy wrote that another biopsy should be done within a few months.

The patient was seen subsequently by his primary care physician, whose office note mentioned the precancerous biopsy findings and indicated that another biopsy was necessary; the physician also wrote that malignancy in the stomach would have to be ruled out eventually. The doctor’s plan called for a repeat gastroscopy to reevaluate the dysplastic polyp. However, neither the primary care physician nor the gastroenterologist took additional steps to order, perform, or refer the patient for a follow-up endoscopy and biopsy of the lesion.

Three years later, the patient developed difficulty swallowing and lost weight rapidly. Diagnostic testing revealed a malignant tumor, at the same location as the polyp, and malignant-appearing lymph nodes.

The patient received a feeding jejunostomy tube and underwent concomitant radiation and chemotherapy. Surgery was planned, but the disease metastasized and was deemed inoperable. Despite additional treatment, the patient died at age 54.

PLAINTIFF’S CLAIM No information about the plaintiff’s claim is available.

DOCTORS’ DEFENSE The primary care physician argued that both he and the gastroenterologist were responsible for making sure the follow-up was done; the gastroenterologist claimed that the primary care physician was solely responsible for follow-up testing.

VERDICT $1.5 million Massachusetts settlement.

COMMENT Poor coordination of care and follow-up of results is a common source of malpractice actions. Keep a paper or electronic “tickler file” for important follow-up issues.

Unaddressed cardiovascular risks prove fatal

A 46-YEAR-OLD MAN went to the hospital, where he was seen by a family practitioner. The physician noted that the patient had a history of smoking, high cholesterol, and thyroid problems.

Early the following month, the patient died of cardiopulmonary arrest. Autopsy results showed arteriosclerotic disease, acute dissection of the coronary plaques, and left ventricular hypertrophy.

PLAINTIFF’S CLAIM The family practitioner failed to take a careful history and prescribe aspirin therapy and cholesterol-lowering medication. The patient should have been referred for a cardiac work-up.

DOCTOR’S DEFENSE The patient was advised of the importance of treatment to correct his condition.

VERDICT $575,000 Michigan settlement.

COMMENT I’m seeing a great increase in cases involving failure to address cardiovascular risk factors. Be sure to thoroughly document refusal of interventions or nonadherence.

Lack of surveillance delays lung cancer diagnosis

A 64-YEAR-OLD MAN was referred to a pulmonary specialist in January by his primary care physician after a computed tomography (CT) scan showed a spiculated density adjacent to the right main-stem bronchus and a prominent right hilar lymph node. The CT scan also revealed a noncalcified nodule in the right middle lobe.

Before examining the patient, the pulmonary specialist ordered a positron emission tomography (PET) scan, which he interpreted as showing no significant uptake and considered negative. He attributed the prominent lymph node to bronchitis and ordered surveillance at 3-month intervals.

A CT scan in May showed no change, but the radiologist noted that “the possibility of malignancy cannot be excluded.” When the patient saw the specialist in early June, the doctor recommended another CT scan in 3 months.

The patient did not return to the specialist until September of the following year. By that time, a CT scan taken a couple of months before (June) as part of preoperative clearance for knee surgery showed that the irregular mass had grown significantly since the CT scan in May of the previous year. A bronchoscopy done in September to evaluate the mass was negative. In November, however, a lymph node biopsy revealed that the patient had metastatic lung cancer. He died about a month later.

PLAINTIFF’S CLAIM Because the patient had a history of smoking and the CT scan revealed a density, the suspicion for cancer should have been high despite a negative PET scan. A specimen should have been obtained by thoracoscopy or thoracotomy to rule out cancer.

THE DEFENSE The pulmonary specialist followed the correct protocol; failure to diagnose cancer at the September visit didn’t affect the outcome because the cancer was already metastatic and incurable. The patient didn’t quit smoking or follow up regularly with his primary care physician. Moreover, the cancer was at least stage IIA when the primary care physician referred the patient to the specialist.

VERDICT Pennsylvania defense verdict.

COMMENT Although a defense verdict was ultimately returned, wouldn’t a “tickler file” or a reminder to the patient (and documentation if the patient failed to follow up as recommended) have been easier?

Follow-up foul-up leads to metastatic disease

A PRECANCEROUS POLYP was found in the stomach of a 50-year-old man during diagnostic gastroscopy. The pathologist’s report noted that an adjacent or underlying malignant process could not be ruled out and recommended additional tissue sampling. Upon reading the report, the gastroenterologist who had performed the gastroscopy wrote that another biopsy should be done within a few months.

The patient was seen subsequently by his primary care physician, whose office note mentioned the precancerous biopsy findings and indicated that another biopsy was necessary; the physician also wrote that malignancy in the stomach would have to be ruled out eventually. The doctor’s plan called for a repeat gastroscopy to reevaluate the dysplastic polyp. However, neither the primary care physician nor the gastroenterologist took additional steps to order, perform, or refer the patient for a follow-up endoscopy and biopsy of the lesion.

Three years later, the patient developed difficulty swallowing and lost weight rapidly. Diagnostic testing revealed a malignant tumor, at the same location as the polyp, and malignant-appearing lymph nodes.

The patient received a feeding jejunostomy tube and underwent concomitant radiation and chemotherapy. Surgery was planned, but the disease metastasized and was deemed inoperable. Despite additional treatment, the patient died at age 54.

PLAINTIFF’S CLAIM No information about the plaintiff’s claim is available.

DOCTORS’ DEFENSE The primary care physician argued that both he and the gastroenterologist were responsible for making sure the follow-up was done; the gastroenterologist claimed that the primary care physician was solely responsible for follow-up testing.

VERDICT $1.5 million Massachusetts settlement.

COMMENT Poor coordination of care and follow-up of results is a common source of malpractice actions. Keep a paper or electronic “tickler file” for important follow-up issues.

Unaddressed cardiovascular risks prove fatal

A 46-YEAR-OLD MAN went to the hospital, where he was seen by a family practitioner. The physician noted that the patient had a history of smoking, high cholesterol, and thyroid problems.

Early the following month, the patient died of cardiopulmonary arrest. Autopsy results showed arteriosclerotic disease, acute dissection of the coronary plaques, and left ventricular hypertrophy.

PLAINTIFF’S CLAIM The family practitioner failed to take a careful history and prescribe aspirin therapy and cholesterol-lowering medication. The patient should have been referred for a cardiac work-up.

DOCTOR’S DEFENSE The patient was advised of the importance of treatment to correct his condition.

VERDICT $575,000 Michigan settlement.

COMMENT I’m seeing a great increase in cases involving failure to address cardiovascular risk factors. Be sure to thoroughly document refusal of interventions or nonadherence.

Lack of surveillance delays lung cancer diagnosis

A 64-YEAR-OLD MAN was referred to a pulmonary specialist in January by his primary care physician after a computed tomography (CT) scan showed a spiculated density adjacent to the right main-stem bronchus and a prominent right hilar lymph node. The CT scan also revealed a noncalcified nodule in the right middle lobe.

Before examining the patient, the pulmonary specialist ordered a positron emission tomography (PET) scan, which he interpreted as showing no significant uptake and considered negative. He attributed the prominent lymph node to bronchitis and ordered surveillance at 3-month intervals.

A CT scan in May showed no change, but the radiologist noted that “the possibility of malignancy cannot be excluded.” When the patient saw the specialist in early June, the doctor recommended another CT scan in 3 months.

The patient did not return to the specialist until September of the following year. By that time, a CT scan taken a couple of months before (June) as part of preoperative clearance for knee surgery showed that the irregular mass had grown significantly since the CT scan in May of the previous year. A bronchoscopy done in September to evaluate the mass was negative. In November, however, a lymph node biopsy revealed that the patient had metastatic lung cancer. He died about a month later.

PLAINTIFF’S CLAIM Because the patient had a history of smoking and the CT scan revealed a density, the suspicion for cancer should have been high despite a negative PET scan. A specimen should have been obtained by thoracoscopy or thoracotomy to rule out cancer.

THE DEFENSE The pulmonary specialist followed the correct protocol; failure to diagnose cancer at the September visit didn’t affect the outcome because the cancer was already metastatic and incurable. The patient didn’t quit smoking or follow up regularly with his primary care physician. Moreover, the cancer was at least stage IIA when the primary care physician referred the patient to the specialist.

VERDICT Pennsylvania defense verdict.

COMMENT Although a defense verdict was ultimately returned, wouldn’t a “tickler file” or a reminder to the patient (and documentation if the patient failed to follow up as recommended) have been easier?

An overlooked finding and missed opportunity

A WOMAN IN HER LATE 70s had an abdominal and pelvic computed tomography (CT) scan, which was reported as normal. Four years later she had a second abdominal and pelvic scan because of blood in her urine. A comparison with the previous scan noted that “the endometrium is thickened, measuring approximately 22 mm, compared to 17 mm” on the first scan.

Endometrial cancer was diagnosed, and the woman underwent a radical hysterectomy and other procedures before being discharged from the hospital. She died about 4 months later of complications from the cancer.

PLAINTIFF’S CLAIM The thickness of the endometrium on the first CT scan should have prompted follow-up because a thickness >10 mm almost always suggests possible endometrial cancer in postmenopausal women. Diagnosing and treating the cancer at the time of the first scan would have prevented metastasis.

THE DEFENSE No information about the defense is available.

VERDICT $600,000 Massachusetts settlement.

COMMENT Incidental findings can be the bane of one’s existence; make sure you read those imaging reports carefully.

A headache, then death, for a 13-year-old

A COMPLAINT OF HEADACHE prompted a 13-year-old girl to seek treatment at a health center. She subsequently developed bacterial meningitis, attributed to sinusitis, and died.

PLAINTIFF’S CLAIM The physician who saw the girl at the health center failed to review records of a previous trip to an emergency room, ask the patient about the severity of her headache, or prescribe antibiotics.

THE DEFENSE No information about the defense is available.

VERDICT $3.75M Illinois verdict.

COMMENT The old lesson of considering not only the most common but also the “have-to-make” diagnoses remains timeless.

Did a failure to communicate cost this patient his life?

A MAN WITH A DRY, NONPRODUCTIVE COUGH and a long history of sinus problems and upper respiratory issues was seen several times by his family care group. One physician ordered a chest radiograph, which a technician performed in house and a radiologist read at another location of the practice. The radiologist compared the radiograph with a chest film done several years earlier and reported a new finding: a 1-cm lung nodule. He recommended further evaluation with a computed tomography (CT) scan.

On the same day as the chest radiograph, the patient was referred to an ear, nose, and throat specialist, who examined him the following day and ordered a CT scan of the sinus. The patient was never notified of the abnormality on the chest radiograph or the need for a follow-up CT scan.

Almost 2 years later, the patient began losing weight and experiencing shortness of breath and chest pain. He went to another medical group and was referred for radiologic evaluation. He was subsequently diagnosed with stage IV terminal lung cancer and died about 9 months later.

PLAINTIFFS’ CLAIM The family care group was negligent for failing to communicate the results of the chest radiograph to the patient. Treatment at the time of the chest x-ray would likely have been curative.

THE DEFENSE No information about the defense is available.

VERDICT $900,000 Virginia settlement.

COMMENT Another abnormal radiograph, another example of inadequate communication leads to a $900,000 settlement.

An overlooked finding and missed opportunity

A WOMAN IN HER LATE 70s had an abdominal and pelvic computed tomography (CT) scan, which was reported as normal. Four years later she had a second abdominal and pelvic scan because of blood in her urine. A comparison with the previous scan noted that “the endometrium is thickened, measuring approximately 22 mm, compared to 17 mm” on the first scan.

Endometrial cancer was diagnosed, and the woman underwent a radical hysterectomy and other procedures before being discharged from the hospital. She died about 4 months later of complications from the cancer.

PLAINTIFF’S CLAIM The thickness of the endometrium on the first CT scan should have prompted follow-up because a thickness >10 mm almost always suggests possible endometrial cancer in postmenopausal women. Diagnosing and treating the cancer at the time of the first scan would have prevented metastasis.

THE DEFENSE No information about the defense is available.

VERDICT $600,000 Massachusetts settlement.

COMMENT Incidental findings can be the bane of one’s existence; make sure you read those imaging reports carefully.

A headache, then death, for a 13-year-old

A COMPLAINT OF HEADACHE prompted a 13-year-old girl to seek treatment at a health center. She subsequently developed bacterial meningitis, attributed to sinusitis, and died.

PLAINTIFF’S CLAIM The physician who saw the girl at the health center failed to review records of a previous trip to an emergency room, ask the patient about the severity of her headache, or prescribe antibiotics.

THE DEFENSE No information about the defense is available.

VERDICT $3.75M Illinois verdict.

COMMENT The old lesson of considering not only the most common but also the “have-to-make” diagnoses remains timeless.

Did a failure to communicate cost this patient his life?

A MAN WITH A DRY, NONPRODUCTIVE COUGH and a long history of sinus problems and upper respiratory issues was seen several times by his family care group. One physician ordered a chest radiograph, which a technician performed in house and a radiologist read at another location of the practice. The radiologist compared the radiograph with a chest film done several years earlier and reported a new finding: a 1-cm lung nodule. He recommended further evaluation with a computed tomography (CT) scan.

On the same day as the chest radiograph, the patient was referred to an ear, nose, and throat specialist, who examined him the following day and ordered a CT scan of the sinus. The patient was never notified of the abnormality on the chest radiograph or the need for a follow-up CT scan.

Almost 2 years later, the patient began losing weight and experiencing shortness of breath and chest pain. He went to another medical group and was referred for radiologic evaluation. He was subsequently diagnosed with stage IV terminal lung cancer and died about 9 months later.

PLAINTIFFS’ CLAIM The family care group was negligent for failing to communicate the results of the chest radiograph to the patient. Treatment at the time of the chest x-ray would likely have been curative.

THE DEFENSE No information about the defense is available.

VERDICT $900,000 Virginia settlement.

COMMENT Another abnormal radiograph, another example of inadequate communication leads to a $900,000 settlement.

An overlooked finding and missed opportunity

A WOMAN IN HER LATE 70s had an abdominal and pelvic computed tomography (CT) scan, which was reported as normal. Four years later she had a second abdominal and pelvic scan because of blood in her urine. A comparison with the previous scan noted that “the endometrium is thickened, measuring approximately 22 mm, compared to 17 mm” on the first scan.

Endometrial cancer was diagnosed, and the woman underwent a radical hysterectomy and other procedures before being discharged from the hospital. She died about 4 months later of complications from the cancer.

PLAINTIFF’S CLAIM The thickness of the endometrium on the first CT scan should have prompted follow-up because a thickness >10 mm almost always suggests possible endometrial cancer in postmenopausal women. Diagnosing and treating the cancer at the time of the first scan would have prevented metastasis.

THE DEFENSE No information about the defense is available.

VERDICT $600,000 Massachusetts settlement.

COMMENT Incidental findings can be the bane of one’s existence; make sure you read those imaging reports carefully.

A headache, then death, for a 13-year-old

A COMPLAINT OF HEADACHE prompted a 13-year-old girl to seek treatment at a health center. She subsequently developed bacterial meningitis, attributed to sinusitis, and died.

PLAINTIFF’S CLAIM The physician who saw the girl at the health center failed to review records of a previous trip to an emergency room, ask the patient about the severity of her headache, or prescribe antibiotics.

THE DEFENSE No information about the defense is available.

VERDICT $3.75M Illinois verdict.

COMMENT The old lesson of considering not only the most common but also the “have-to-make” diagnoses remains timeless.

Did a failure to communicate cost this patient his life?

A MAN WITH A DRY, NONPRODUCTIVE COUGH and a long history of sinus problems and upper respiratory issues was seen several times by his family care group. One physician ordered a chest radiograph, which a technician performed in house and a radiologist read at another location of the practice. The radiologist compared the radiograph with a chest film done several years earlier and reported a new finding: a 1-cm lung nodule. He recommended further evaluation with a computed tomography (CT) scan.

On the same day as the chest radiograph, the patient was referred to an ear, nose, and throat specialist, who examined him the following day and ordered a CT scan of the sinus. The patient was never notified of the abnormality on the chest radiograph or the need for a follow-up CT scan.

Almost 2 years later, the patient began losing weight and experiencing shortness of breath and chest pain. He went to another medical group and was referred for radiologic evaluation. He was subsequently diagnosed with stage IV terminal lung cancer and died about 9 months later.

PLAINTIFFS’ CLAIM The family care group was negligent for failing to communicate the results of the chest radiograph to the patient. Treatment at the time of the chest x-ray would likely have been curative.

THE DEFENSE No information about the defense is available.

VERDICT $900,000 Virginia settlement.

COMMENT Another abnormal radiograph, another example of inadequate communication leads to a $900,000 settlement.

Bladder and bowel function lost to cauda equina syndrome

LOWER BACK PAIN developed in a 34-year-old woman around the time she had fibroids removed by her obstetrician-gynecologist. The woman reported the pain at her first postoperative visit. The OB/GYN offered treatment, but the patient traveled to the Dominican Republic for 2 months instead.

The month after the patient’s return, she experienced sharp pain in her legs and temporarily lost control of her bladder and bowels. Eight days later, she returned to the OB/GYN complaining of pain and occasional urinary incontinence. The doctor diagnosed neurogenic bladder, prescribed medication, and told the patient to follow up in a week. At some point over the next few days, the patient could not urinate, but didn’t return to the doctor for a week. The doctor catheterized her and drained about 3000 mL of urine. He then sent her to a hospital.

The hospital staff suspected cauda equina syndrome and consulted a neurologist, who concluded that the patient didn’t have the condition. The patient refused a magnetic resonance imaging (MRI) scan at that time because she didn’t think she could assume the required position. The patient ultimately underwent an MRI scan a week later. Another neurologist reviewed the scan and diagnosed cauda equina syndrome. Despite surgery, the patient has permanent bowel and bladder dysfunction.

PLAINTIFF’S CLAIM The defendants were negligent in failing to diagnose cauda equina syndrome earlier.

DOCTORS’ DEFENSE The OB/GYN claimed that the patient didn’t undergo the recommended follow-up treatment after surgery. The neurologist claimed that his examination didn’t reveal any objective indications of cauda equina syndrome.

VERDICT $1.5 million New York settlement.

COMMENT Suspicion of cauda equina demands prompt imaging and neurologic consultation. Failure to do so can lead to devastating consequences.

Failure to suspect stroke results in brain damage

A 37-YEAR-OLD WOMAN went to a gastroenterologist for a postoperative consult. Her blood pressure was 180/100. Her medical history included recent symptoms of blurred vision, dizziness, nosebleeds, and tingling in the face and right arm. She was taking medications that increased her risk of stroke, had preexisting Crohn’s disease, and smoked.

The day after the doctor visit, the woman went to a hospital, where she was diagnosed with a stroke from a left cerebral artery infarction and dissection with clot formation in the left internal carotid artery. She suffered brain damage with aphasia and right hemiparalysis.

PLAINTIFF’S CLAIM The doctor was negligent for failing to diagnose the patient’s condition and provide treatment.

DOCTOR’S DEFENSE The doctor denied any negligence.

VERDICT Indiana defense verdict.

COMMENT In this age of thrombolysis and aggressive stroke management, rapid diagnosis and intervention has gone from an academic exercise to a standard of care.

Suspicious finding + no follow-up = lawsuit

CONGESTIVE HEART FAILURE and atrial fibrillation prompted the hospitalization of a 79-year-old woman. A radiograph showed a density in the upper left lobe of her lung, and another x-ray was ordered. The same radiologist reviewed both films and recommended that the patient undergo a third radiograph after discharge from the hospital. Although informed of the radiologist’s findings and recommendations, the patient’s physician didn’t order a radiograph or computed tomography (CT) scan. The patient wasn’t notified of the findings.

The density was still visible on radiographs taken about 19 months after the original films. Seventeen months later, the patient complained of left chest wall discomfort and had another radiograph, which showed the density and a collection of pleural fluid. A CT scan suggested cancer. The patient was ultimately diagnosed with stage-III, poorly differentiated adenocarcinoma—which has a very low survival rate—in her left pleura. Because of the prognosis, a biopsy wasn’t performed.

PLAINTIFF’S CLAIM The defendant was negligent in failing to follow up on the radiologist’s report. Proper diagnosis and treatment at the time of the original radiographs would have meant targeting the cancer at stage I, when the survival rate would have been much higher.

THE DEFENSE The primary lung cancer wasn’t in the upper left lobe, and the density was probably only a scar. The cancer was likely somewhere else, possibly the gastrointestinal tract.

VERDICT $500,000 Massachusetts arbitration award.

COMMENT Poor handoffs in care, especially follow-up of abnormal imaging tests, such as a lung or breast mass, remain an all too common cause of malpractice claims.

Doctor crosses line, pays the price

A WOMAN BECAME SEXUALLY INVOLVED with her family practitioner, an affair she claimed the doctor initiated while he was treating her for anxiety and depression. She said the physician-patient relationship had begun more than a year before the sexual involvement when she learned that her infant daughter had cerebral palsy; the doctor prescribed paroxetine and bupropion.

The affair ended about 10 months after it began. The patient said it caused her marriage to deteriorate.

PLAINTIFF’S CLAIM The patient couldn’t exercise independent judgment because she was experiencing eroticized transference; the doctor mishandled the transference phenomenon.

THE DEFENSE The sexual relationship was brief and ended 6 months before the doctor treated the patient.

VERDICT $416,500 net verdict in New York.

COMMENT It’s never prudent to become involved sexually with a patient.

Bladder and bowel function lost to cauda equina syndrome

LOWER BACK PAIN developed in a 34-year-old woman around the time she had fibroids removed by her obstetrician-gynecologist. The woman reported the pain at her first postoperative visit. The OB/GYN offered treatment, but the patient traveled to the Dominican Republic for 2 months instead.

The month after the patient’s return, she experienced sharp pain in her legs and temporarily lost control of her bladder and bowels. Eight days later, she returned to the OB/GYN complaining of pain and occasional urinary incontinence. The doctor diagnosed neurogenic bladder, prescribed medication, and told the patient to follow up in a week. At some point over the next few days, the patient could not urinate, but didn’t return to the doctor for a week. The doctor catheterized her and drained about 3000 mL of urine. He then sent her to a hospital.

The hospital staff suspected cauda equina syndrome and consulted a neurologist, who concluded that the patient didn’t have the condition. The patient refused a magnetic resonance imaging (MRI) scan at that time because she didn’t think she could assume the required position. The patient ultimately underwent an MRI scan a week later. Another neurologist reviewed the scan and diagnosed cauda equina syndrome. Despite surgery, the patient has permanent bowel and bladder dysfunction.

PLAINTIFF’S CLAIM The defendants were negligent in failing to diagnose cauda equina syndrome earlier.

DOCTORS’ DEFENSE The OB/GYN claimed that the patient didn’t undergo the recommended follow-up treatment after surgery. The neurologist claimed that his examination didn’t reveal any objective indications of cauda equina syndrome.

VERDICT $1.5 million New York settlement.

COMMENT Suspicion of cauda equina demands prompt imaging and neurologic consultation. Failure to do so can lead to devastating consequences.

Failure to suspect stroke results in brain damage

A 37-YEAR-OLD WOMAN went to a gastroenterologist for a postoperative consult. Her blood pressure was 180/100. Her medical history included recent symptoms of blurred vision, dizziness, nosebleeds, and tingling in the face and right arm. She was taking medications that increased her risk of stroke, had preexisting Crohn’s disease, and smoked.

The day after the doctor visit, the woman went to a hospital, where she was diagnosed with a stroke from a left cerebral artery infarction and dissection with clot formation in the left internal carotid artery. She suffered brain damage with aphasia and right hemiparalysis.

PLAINTIFF’S CLAIM The doctor was negligent for failing to diagnose the patient’s condition and provide treatment.

DOCTOR’S DEFENSE The doctor denied any negligence.

VERDICT Indiana defense verdict.

COMMENT In this age of thrombolysis and aggressive stroke management, rapid diagnosis and intervention has gone from an academic exercise to a standard of care.

Suspicious finding + no follow-up = lawsuit

CONGESTIVE HEART FAILURE and atrial fibrillation prompted the hospitalization of a 79-year-old woman. A radiograph showed a density in the upper left lobe of her lung, and another x-ray was ordered. The same radiologist reviewed both films and recommended that the patient undergo a third radiograph after discharge from the hospital. Although informed of the radiologist’s findings and recommendations, the patient’s physician didn’t order a radiograph or computed tomography (CT) scan. The patient wasn’t notified of the findings.

The density was still visible on radiographs taken about 19 months after the original films. Seventeen months later, the patient complained of left chest wall discomfort and had another radiograph, which showed the density and a collection of pleural fluid. A CT scan suggested cancer. The patient was ultimately diagnosed with stage-III, poorly differentiated adenocarcinoma—which has a very low survival rate—in her left pleura. Because of the prognosis, a biopsy wasn’t performed.

PLAINTIFF’S CLAIM The defendant was negligent in failing to follow up on the radiologist’s report. Proper diagnosis and treatment at the time of the original radiographs would have meant targeting the cancer at stage I, when the survival rate would have been much higher.

THE DEFENSE The primary lung cancer wasn’t in the upper left lobe, and the density was probably only a scar. The cancer was likely somewhere else, possibly the gastrointestinal tract.

VERDICT $500,000 Massachusetts arbitration award.

COMMENT Poor handoffs in care, especially follow-up of abnormal imaging tests, such as a lung or breast mass, remain an all too common cause of malpractice claims.

Doctor crosses line, pays the price

A WOMAN BECAME SEXUALLY INVOLVED with her family practitioner, an affair she claimed the doctor initiated while he was treating her for anxiety and depression. She said the physician-patient relationship had begun more than a year before the sexual involvement when she learned that her infant daughter had cerebral palsy; the doctor prescribed paroxetine and bupropion.

The affair ended about 10 months after it began. The patient said it caused her marriage to deteriorate.

PLAINTIFF’S CLAIM The patient couldn’t exercise independent judgment because she was experiencing eroticized transference; the doctor mishandled the transference phenomenon.

THE DEFENSE The sexual relationship was brief and ended 6 months before the doctor treated the patient.

VERDICT $416,500 net verdict in New York.

COMMENT It’s never prudent to become involved sexually with a patient.

Bladder and bowel function lost to cauda equina syndrome

LOWER BACK PAIN developed in a 34-year-old woman around the time she had fibroids removed by her obstetrician-gynecologist. The woman reported the pain at her first postoperative visit. The OB/GYN offered treatment, but the patient traveled to the Dominican Republic for 2 months instead.

The month after the patient’s return, she experienced sharp pain in her legs and temporarily lost control of her bladder and bowels. Eight days later, she returned to the OB/GYN complaining of pain and occasional urinary incontinence. The doctor diagnosed neurogenic bladder, prescribed medication, and told the patient to follow up in a week. At some point over the next few days, the patient could not urinate, but didn’t return to the doctor for a week. The doctor catheterized her and drained about 3000 mL of urine. He then sent her to a hospital.

The hospital staff suspected cauda equina syndrome and consulted a neurologist, who concluded that the patient didn’t have the condition. The patient refused a magnetic resonance imaging (MRI) scan at that time because she didn’t think she could assume the required position. The patient ultimately underwent an MRI scan a week later. Another neurologist reviewed the scan and diagnosed cauda equina syndrome. Despite surgery, the patient has permanent bowel and bladder dysfunction.

PLAINTIFF’S CLAIM The defendants were negligent in failing to diagnose cauda equina syndrome earlier.

DOCTORS’ DEFENSE The OB/GYN claimed that the patient didn’t undergo the recommended follow-up treatment after surgery. The neurologist claimed that his examination didn’t reveal any objective indications of cauda equina syndrome.

VERDICT $1.5 million New York settlement.

COMMENT Suspicion of cauda equina demands prompt imaging and neurologic consultation. Failure to do so can lead to devastating consequences.

Failure to suspect stroke results in brain damage

A 37-YEAR-OLD WOMAN went to a gastroenterologist for a postoperative consult. Her blood pressure was 180/100. Her medical history included recent symptoms of blurred vision, dizziness, nosebleeds, and tingling in the face and right arm. She was taking medications that increased her risk of stroke, had preexisting Crohn’s disease, and smoked.

The day after the doctor visit, the woman went to a hospital, where she was diagnosed with a stroke from a left cerebral artery infarction and dissection with clot formation in the left internal carotid artery. She suffered brain damage with aphasia and right hemiparalysis.

PLAINTIFF’S CLAIM The doctor was negligent for failing to diagnose the patient’s condition and provide treatment.

DOCTOR’S DEFENSE The doctor denied any negligence.

VERDICT Indiana defense verdict.

COMMENT In this age of thrombolysis and aggressive stroke management, rapid diagnosis and intervention has gone from an academic exercise to a standard of care.

Suspicious finding + no follow-up = lawsuit

CONGESTIVE HEART FAILURE and atrial fibrillation prompted the hospitalization of a 79-year-old woman. A radiograph showed a density in the upper left lobe of her lung, and another x-ray was ordered. The same radiologist reviewed both films and recommended that the patient undergo a third radiograph after discharge from the hospital. Although informed of the radiologist’s findings and recommendations, the patient’s physician didn’t order a radiograph or computed tomography (CT) scan. The patient wasn’t notified of the findings.

The density was still visible on radiographs taken about 19 months after the original films. Seventeen months later, the patient complained of left chest wall discomfort and had another radiograph, which showed the density and a collection of pleural fluid. A CT scan suggested cancer. The patient was ultimately diagnosed with stage-III, poorly differentiated adenocarcinoma—which has a very low survival rate—in her left pleura. Because of the prognosis, a biopsy wasn’t performed.

PLAINTIFF’S CLAIM The defendant was negligent in failing to follow up on the radiologist’s report. Proper diagnosis and treatment at the time of the original radiographs would have meant targeting the cancer at stage I, when the survival rate would have been much higher.

THE DEFENSE The primary lung cancer wasn’t in the upper left lobe, and the density was probably only a scar. The cancer was likely somewhere else, possibly the gastrointestinal tract.

VERDICT $500,000 Massachusetts arbitration award.

COMMENT Poor handoffs in care, especially follow-up of abnormal imaging tests, such as a lung or breast mass, remain an all too common cause of malpractice claims.

Doctor crosses line, pays the price

A WOMAN BECAME SEXUALLY INVOLVED with her family practitioner, an affair she claimed the doctor initiated while he was treating her for anxiety and depression. She said the physician-patient relationship had begun more than a year before the sexual involvement when she learned that her infant daughter had cerebral palsy; the doctor prescribed paroxetine and bupropion.

The affair ended about 10 months after it began. The patient said it caused her marriage to deteriorate.

PLAINTIFF’S CLAIM The patient couldn’t exercise independent judgment because she was experiencing eroticized transference; the doctor mishandled the transference phenomenon.

THE DEFENSE The sexual relationship was brief and ended 6 months before the doctor treated the patient.

VERDICT $416,500 net verdict in New York.

COMMENT It’s never prudent to become involved sexually with a patient.

Car accident blamed on lack of post-test monitoring

AN IN-OFFICE FASTING BLOOD TEST was performed at a medical clinic on a 53-year-old man with diabetes. The man had been hospitalized recently with life-threatening complications arising from poor management of his diabetes. He hadn’t eaten or taken any medication, including insulin, in the 12 hours before the test.

After his blood was taken, the patient was told that he could leave the clinic. Shortly afterwards, another patient reported that a man in the parking lot was acting confused and disoriented.

Office personnel read the blood test results—which showed a blood sugar level <50 mg/dL—and called the man’s wife.

Almost immediately afterward, the wife received a call from the police informing her that her husband had been in a single-car rollover accident. He suffered a stable T12 compression fracture. His blood sugar, taken by paramedics, was 24. The patient said he was unaware of his hypoglycemia and impaired cognitive function.

PLAINTIFF’S CLAIM The clinic didn’t have policies and procedures for testing fasting blood sugar in patients with diabetes, who have a known risk of hypoglycemia. The clinic shouldn’t have allowed a fasting patient with diabetes to leave before his blood tests were complete and he had eaten a snack.

THE DEFENSE The only explanation for the drop in the patient’s blood sugar was that he had taken his morning insulin in disregard of his doctor’s orders. Patients who are unaware of their hypoglycemia often show no outward signs of impairment. The patient failed to take responsibility for educating himself about his disease and managing it properly.

VERDICT $400,000 Missouri settlement.

COMMENT Clear office policies and procedures can reduce the risk of lawsuits.

Car accident blamed on lack of post-test monitoring

AN IN-OFFICE FASTING BLOOD TEST was performed at a medical clinic on a 53-year-old man with diabetes. The man had been hospitalized recently with life-threatening complications arising from poor management of his diabetes. He hadn’t eaten or taken any medication, including insulin, in the 12 hours before the test.

After his blood was taken, the patient was told that he could leave the clinic. Shortly afterwards, another patient reported that a man in the parking lot was acting confused and disoriented.

Office personnel read the blood test results—which showed a blood sugar level <50 mg/dL—and called the man’s wife.

Almost immediately afterward, the wife received a call from the police informing her that her husband had been in a single-car rollover accident. He suffered a stable T12 compression fracture. His blood sugar, taken by paramedics, was 24. The patient said he was unaware of his hypoglycemia and impaired cognitive function.

PLAINTIFF’S CLAIM The clinic didn’t have policies and procedures for testing fasting blood sugar in patients with diabetes, who have a known risk of hypoglycemia. The clinic shouldn’t have allowed a fasting patient with diabetes to leave before his blood tests were complete and he had eaten a snack.

THE DEFENSE The only explanation for the drop in the patient’s blood sugar was that he had taken his morning insulin in disregard of his doctor’s orders. Patients who are unaware of their hypoglycemia often show no outward signs of impairment. The patient failed to take responsibility for educating himself about his disease and managing it properly.

VERDICT $400,000 Missouri settlement.

COMMENT Clear office policies and procedures can reduce the risk of lawsuits.

Car accident blamed on lack of post-test monitoring

AN IN-OFFICE FASTING BLOOD TEST was performed at a medical clinic on a 53-year-old man with diabetes. The man had been hospitalized recently with life-threatening complications arising from poor management of his diabetes. He hadn’t eaten or taken any medication, including insulin, in the 12 hours before the test.

After his blood was taken, the patient was told that he could leave the clinic. Shortly afterwards, another patient reported that a man in the parking lot was acting confused and disoriented.

Office personnel read the blood test results—which showed a blood sugar level <50 mg/dL—and called the man’s wife.

Almost immediately afterward, the wife received a call from the police informing her that her husband had been in a single-car rollover accident. He suffered a stable T12 compression fracture. His blood sugar, taken by paramedics, was 24. The patient said he was unaware of his hypoglycemia and impaired cognitive function.

PLAINTIFF’S CLAIM The clinic didn’t have policies and procedures for testing fasting blood sugar in patients with diabetes, who have a known risk of hypoglycemia. The clinic shouldn’t have allowed a fasting patient with diabetes to leave before his blood tests were complete and he had eaten a snack.

THE DEFENSE The only explanation for the drop in the patient’s blood sugar was that he had taken his morning insulin in disregard of his doctor’s orders. Patients who are unaware of their hypoglycemia often show no outward signs of impairment. The patient failed to take responsibility for educating himself about his disease and managing it properly.

VERDICT $400,000 Missouri settlement.

COMMENT Clear office policies and procedures can reduce the risk of lawsuits.