Failure to follow up on chest X-ray
On January 29, 2019, a 59-year-old woman came to Cardiologist A for a scheduled left heart catheterization. The patient’s medical history included myocardial infarction, congestive heart failure, defibrillator placement, and heart catheterization with stent placement.
Failure to follow up on chest X-ray
On January 29, 2019, a 59-year-old woman came to Cardiologist A for a scheduled left heart catheterization. The patient’s medical history included myocardial infarction, congestive heart failure, defibrillator placement, and heart catheterization with stent placement.
Presentation
On January 29, 2019, a 59-year-old woman came to Cardiologist A for a scheduled left heart catheterization. The patient’s medical history included myocardial infarction, congestive heart failure, defibrillator (ICD) placement, and heart catheterization with stent placement. She was also a heavy smoker.
Physician action
As part of the preoperative work up, Cardiologist A ordered a chest X-ray, completed on January 25, 2019.
The chest X-ray revealed a left hilar opacity and the radiologist recommended further evaluation with a contrast CT scan of the chest. Cardiologist A did not see the report before he performed the heart catheterization on January 29. He testified that staff from the catheterization lab usually reviewed preoperative test results and let him know if there were any abnormal results.
On March 23, 2019, — eight weeks after the catheterization — a copy of the chest X-ray report was faxed to the patient’s family practice clinic. Family Physician A, the patient’s primary care physician, was copied on the report. However, the patient had only been seen by Physician Assistant A at this clinic from February 2015 to May 2017, never by Family Physician A.
The clinic’s receptionist scanned the X-ray report and sent it to Physician Assistant A. However, the log maintained by the practice did not reflect that it was sent and received by the PA. Family Physician A and Physician Assistant A both testified they did not receive or review the report.
On May 12, 2019, Cardiologist B (an electrophysiologist) ordered a chest X-ray ahead of an ICD generator change that was scheduled for May 14, 2019. The radiologist compared the May 2019 chest X-ray with the January 2019 chest X-ray and noted that the left hilar opacity was “not visualized on the present exam and may be obscured by the pacemaker battery pack.” Cardiologist B did not review or follow up on the chest X-ray report.
The May 12 chest X-ray report was sent to the family practice clinic on the same day. The log showed the receptionist scanned the report and sent it to Physician Assistant A, who reviewed it that day.
The patient had two more chest X-rays — pre-operatively on September 19, 2019, and post-operatively on September 24, 2019. These chest X-rays were ordered by Cardiologist C, who performed an ICD pocket revision on September 24. The September 19th X-ray noted “no acute cardiopulmonary process”, but the radiology report from the September 24th X-ray noted a “4.7 cm patchy opacity in the left mid-lung.” The differential diagnoses included pneumonia, pulmonary hemorrhage, and mass. The radiologist recommended a CT scan of the chest with contrast.
Cardiologist C was copied on the September 24th report and said he never saw it. He did not generally order post-operative X-rays, so he is not sure why it was ordered (by a nurse practitioner). The September 19th X-ray was sent to the family practice clinic and reviewed by Physician Assistant A. The September 24th X-ray included Family Physician A’s name on the report as a recipient, and it was reportedly faxed to the clinic. Family Physician A testified it was never received at his office, and it was not part of the patient’s medical record. There was no log entry indicating the report had been received.
Cardiologist A continued treating the patient’s cardiac issues. On April 8, 2020, a CT coronary angiogram revealed a mass measuring 5.5 cm, likely extending to the left hilum in the left upper lung. A chest CT was recommended.
Cardiologist A ordered a stat pulmonary function test and a PET scan. The patient was referred to a cardiovascular surgeon for evaluation of the left lung mass. She was diagnosed with left upper lobe adenocarcinoma and ductal carcinoma of the left breast with lymph node metastases.
On April 9, 2020, Family Physician A was copied on the April 8 angiogram report, and it was added to the patient’s chart. The clinic’s receptionist also scanned the report upon receipt and sent it to Physician Assistant A, who noted the report had been received. Physician Assistant A contacted the patient to ask if anyone had discussed the findings with her. The patient indicated that she was aware and was following up with a specialist.
The patient received chemotherapy and thoracic radiation treatments over the next several months. She was later diagnosed with metastasis to the brain and was referred to hospice care. She died on April 2, 2022.
Allegations
A lawsuit was filed against Cardiologist A, Cardiologist C, Family Physician A, Physician Assistant A, and the family practice clinic. The allegations against the family practice defendants were failure to review the January 25, 2019 chest X-ray and follow up with the patient to ensure the recommended CT scan was ordered and treatment initiated.
Legal implications
At issue in the case against Physician Assistant A and Family Physician A was whether these defendants received a copy of the January 25, 2019 chest X-ray report and what duty they had to act on the results. Neither of these defendants ordered the chest X-ray nor referred the patient to Cardiologist A. When the lawsuit was filed, the patient had not been seen in the family medicine clinic for two years.
The defense argued that Cardiologist A — who ordered the January 25, 2019 chest X-ray — had a better opportunity to act on the results on the day of the patient’s catheterization or upon follow up. As the ordering physician, Cardiologist A bore the primary responsibility for reviewing the chest X-ray results and ensuring the recommended CT scan was pursued. Yet, his reliance on catheterization lab staff to flag abnormal results — without a formal verification process — created a critical gap.
That said, primary care physicians who are copied on outside diagnostic reports are not without responsibility. Shared receipt of results can mean shared accountability.
Family physicians who reviewed this case for the defense stated that if the defendants were aware of the results from the X-rays, reasonable treatment would have been to notify the patient about the abnormal findings or verify that the patient was being treated by another physician.
In fact, this is what occurred when Physician Assistant A received the results of the April 8, 2020 angiogram report. Physician Assistant A called the patient to ensure she knew about the results and that she was being treated. This lent credibility to the defendants’ statements that they did not receive the results from the chest X-rays taken on January 25 and September 24, 2019.
The plaintiff’s expert — an oncologist — stated that even if the family practice defendants did not order the chest X-rays, if they received and reviewed the results, the standard of care is the same as the ordering physician. He argued that these defendants should have made the appropriate work up or referral recommendation since they were the patient’s primary care providers and were copied on the results.
Whether or not this argument would prevail in court, this risk exposure highlights the need for a reliable, documented system for receiving, routing, and acknowledging review of outside reports. This includes logging receipt, assigning responsibility for review, and documenting any action taken — whether that means contacting the patient, contacting the ordering physician, or noting that no follow up was warranted.
The plaintiff’s expert further claimed that if the patient had been diagnosed with lung cancer in January 2019, she would have been a candidate for surgery. This would have greatly increased her chance of survival.
Disposition
This case was settled on behalf of Cardiologist A and Family Physician A. The case against Cardiologist C was dropped.
Risk management for adult primary care physicians
More about failure to follow up
Disclaimer
Presentation
On January 29, 2019, a 59-year-old woman came to Cardiologist A for a scheduled left heart catheterization. The patient’s medical history included myocardial infarction, congestive heart failure, defibrillator (ICD) placement, and heart catheterization with stent placement. She was also a heavy smoker.
Physician action
As part of the preoperative work up, Cardiologist A ordered a chest X-ray, completed on January 25, 2019.
The chest X-ray revealed a left hilar opacity and the radiologist recommended further evaluation with a contrast CT scan of the chest. Cardiologist A did not see the report before he performed the heart catheterization on January 29. He testified that staff from the catheterization lab usually reviewed preoperative test results and let him know if there were any abnormal results.
On March 23, 2019, — eight weeks after the catheterization — a copy of the chest X-ray report was faxed to the patient’s family practice clinic. Family Physician A, the patient’s primary care physician, was copied on the report. However, the patient had only been seen by Physician Assistant A at this clinic from February 2015 to May 2017, never by Family Physician A.
The clinic’s receptionist scanned the X-ray report and sent it to Physician Assistant A. However, the log maintained by the practice did not reflect that it was sent and received by the PA. Family Physician A and Physician Assistant A both testified they did not receive or review the report.
On May 12, 2019, Cardiologist B (an electrophysiologist) ordered a chest X-ray ahead of an ICD generator change that was scheduled for May 14, 2019. The radiologist compared the May 2019 chest X-ray with the January 2019 chest X-ray and noted that the left hilar opacity was “not visualized on the present exam and may be obscured by the pacemaker battery pack.” Cardiologist B did not review or follow up on the chest X-ray report.
The May 12 chest X-ray report was sent to the family practice clinic on the same day. The log showed the receptionist scanned the report and sent it to Physician Assistant A, who reviewed it that day.
The patient had two more chest X-rays — pre-operatively on September 19, 2019, and post-operatively on September 24, 2019. These chest X-rays were ordered by Cardiologist C, who performed an ICD pocket revision on September 24. The September 19th X-ray noted “no acute cardiopulmonary process”, but the radiology report from the September 24th X-ray noted a “4.7 cm patchy opacity in the left mid-lung.” The differential diagnoses included pneumonia, pulmonary hemorrhage, and mass. The radiologist recommended a CT scan of the chest with contrast.
Cardiologist C was copied on the September 24th report and said he never saw it. He did not generally order post-operative X-rays, so he is not sure why it was ordered (by a nurse practitioner). The September 19th X-ray was sent to the family practice clinic and reviewed by Physician Assistant A. The September 24th X-ray included Family Physician A’s name on the report as a recipient, and it was reportedly faxed to the clinic. Family Physician A testified it was never received at his office, and it was not part of the patient’s medical record. There was no log entry indicating the report had been received.
Cardiologist A continued treating the patient’s cardiac issues. On April 8, 2020, a CT coronary angiogram revealed a mass measuring 5.5 cm, likely extending to the left hilum in the left upper lung. A chest CT was recommended.
Cardiologist A ordered a stat pulmonary function test and a PET scan. The patient was referred to a cardiovascular surgeon for evaluation of the left lung mass. She was diagnosed with left upper lobe adenocarcinoma and ductal carcinoma of the left breast with lymph node metastases.
On April 9, 2020, Family Physician A was copied on the April 8 angiogram report, and it was added to the patient’s chart. The clinic’s receptionist also scanned the report upon receipt and sent it to Physician Assistant A, who noted the report had been received. Physician Assistant A contacted the patient to ask if anyone had discussed the findings with her. The patient indicated that she was aware and was following up with a specialist.
The patient received chemotherapy and thoracic radiation treatments over the next several months. She was later diagnosed with metastasis to the brain and was referred to hospice care. She died on April 2, 2022.
Allegations
A lawsuit was filed against Cardiologist A, Cardiologist C, Family Physician A, Physician Assistant A, and the family practice clinic. The allegations against the family practice defendants were failure to review the January 25, 2019 chest X-ray and follow up with the patient to ensure the recommended CT scan was ordered and treatment initiated.
Legal implications
At issue in the case against Physician Assistant A and Family Physician A was whether these defendants received a copy of the January 25, 2019 chest X-ray report and what duty they had to act on the results. Neither of these defendants ordered the chest X-ray nor referred the patient to Cardiologist A. When the lawsuit was filed, the patient had not been seen in the family medicine clinic for two years.
The defense argued that Cardiologist A — who ordered the January 25, 2019 chest X-ray — had a better opportunity to act on the results on the day of the patient’s catheterization or upon follow up. As the ordering physician, Cardiologist A bore the primary responsibility for reviewing the chest X-ray results and ensuring the recommended CT scan was pursued. Yet, his reliance on catheterization lab staff to flag abnormal results — without a formal verification process — created a critical gap.
That said, primary care physicians who are copied on outside diagnostic reports are not without responsibility. Shared receipt of results can mean shared accountability.
Family physicians who reviewed this case for the defense stated that if the defendants were aware of the results from the X-rays, reasonable treatment would have been to notify the patient about the abnormal findings or verify that the patient was being treated by another physician.
In fact, this is what occurred when Physician Assistant A received the results of the April 8, 2020 angiogram report. Physician Assistant A called the patient to ensure she knew about the results and that she was being treated. This lent credibility to the defendants’ statements that they did not receive the results from the chest X-rays taken on January 25 and September 24, 2019.
The plaintiff’s expert — an oncologist — stated that even if the family practice defendants did not order the chest X-rays, if they received and reviewed the results, the standard of care is the same as the ordering physician. He argued that these defendants should have made the appropriate work up or referral recommendation since they were the patient’s primary care providers and were copied on the results.
Whether or not this argument would prevail in court, this risk exposure highlights the need for a reliable, documented system for receiving, routing, and acknowledging review of outside reports. This includes logging receipt, assigning responsibility for review, and documenting any action taken — whether that means contacting the patient, contacting the ordering physician, or noting that no follow up was warranted.
The plaintiff’s expert further claimed that if the patient had been diagnosed with lung cancer in January 2019, she would have been a candidate for surgery. This would have greatly increased her chance of survival.
Disposition
This case was settled on behalf of Cardiologist A and Family Physician A. The case against Cardiologist C was dropped.
Risk management for adult primary care physicians
More about failure to follow up
Disclaimer
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