Presentation

On June 21, a 59-year-old woman came to Hospital A’s emergency department (ED) with fever, chills, severe abdominal pain, and edema in the left leg. Her surgical history included an uncomplicated left total knee arthroplasty, performed two days earlier at the same hospital.

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Physician action

Emergency Medicine (EM) Physician A admitted the patient and ordered labs, imaging of the post-surgical knee, and a CT of the abdomen and pelvis at 6:52 p.m.
 
At 4 a.m. on June 22, before the imaging had been evaluated by a radiologist, Hospitalist A examined the patient. While Hospitalist A was documenting this visit in the EHR, he saw that a radiologist had completed an interpretation of the imaging studies. The abdomen and pelvis CT showed a large mass on the patient’s pancreas.
 
Radiologist A noted a 4 x 4 cm hypodense lesion in the pancreatic tail that could be a pseudocyst or another type of mass. Colonic diverticulitis was also noted. Radiologist A recommended a follow-up multiphasic CT or MRI with pancreatic protocol.
 
Hospitalist A copied the CT report into the patient record and documented that the patient had a pancreatic mass. He also noted that the patient was not aware of this finding and would need to be told before any follow-up scanning could be completed.
 
Hospitalist A also documented that the attending physician — EM Physician A — would need to decide on whether to resume the patient’s anticoagulation therapy for DVT prophylaxis, depending on whether the patient would undergo surgical intervention for the mass.   
 
Later that morning, the patient was examined and cleared for discharge by Orthopedic Surgeon A, who had performed the knee arthroplasty four days earlier. Orthopedic Surgeon A only reviewed the X-ray of the knee before discharging the patient. He did not review the other reports from EM Physician A, Hospitalist A, or Radiologist A. The patient was discharged to home at 10 a.m.
 
Hospitalist B drafted and signed the patient’s discharge summary but failed to mention in the record or tell the patient about the CT finding of the pancreatic mass or the recommendation to obtain additional studies and follow up with a specialist.
 
Post-discharge documentation did note that the patient’s blood cultures returned positive for E. coli after discharge. The patient was contacted and prescribed a 10-day course of sulfamethoxazole/trimethoprim. She was advised to follow up with her primary care physician and Orthopedic Surgeon A within one week.
 
Nearly two years later, the patient came to Hospital B with atrial fibrillation. A CT scan was ordered, and the ordering physician documented a large mass on the patient’s pancreatic tail with local invasion into the kidney and spleen. The CT scan also found lesions in the patient’s liver and chest that were “concerning for metastases.”
 
The patient was diagnosed with Stage IV pancreatic adenocarcinoma. She was treated with six rounds of chemotherapy. Seven months after the treatment began, the patient discontinued chemotherapy.  She died three months later.

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Allegations

A lawsuit was filed against Hospitalists A and B, and Hospital A (employer of Orthopedic Surgeon A and EM Physician A). The allegations were failure to notify the patient of the CT scan results, which resulted in delayed diagnosis and treatment for pancreatic cancer and the patient’s death.  

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Legal implications

Radiologists who reviewed this case for the defense were critical of both Hospitalist A and B for failure to tell the patient about the pancreatic mass. While other physicians had access to the CT results, Hospitalists A and B carried the most responsibility to ensure follow up, according to these reviewers.
 
One consultant stated that Hospitalist B failed to meet the standard of care because the “abnormal finding” on the CT was highlighted in red in the patient record and should have been reviewed at the time of discharge. This consultant also pointed out that the patient was only in the hospital for one day and Hospitalist B should have been able to thoroughly review the limited number of notes for this patient.
 
Regarding the actions of Hospitalist A, consultants stated that he met the standard of care by documenting the finding and handing off the patient to the attending physician, EM Physician A. They also agreed that it was reasonable for Hospitalist A to rely on the subsequent treating physician to read his note and tell the patient about the mass.  
 
Hospitalist A testified that he did not tell the patient about the mass because when he discovered the radiology report at 4:30 a.m., the patient was medicated and presumed to be asleep. The radiology report also stated that Radiologist A personally told EM Physician A about the findings. Hospitalist A relied on EM Physician A to tell the patient about the mass, and he also expected the findings to appear in the patient’s discharge summary.
 
Consultants reviewing this case for both the defense and plaintiff were also critical of EM Physician A and Orthopedic Surgeon A for not reading the patient’s test results and communicating with the patient.

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Disposition

This case was settled on behalf of Hospitalists A and B. The outcome of the case against Hospital A is unknown.
 

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