Failure to properly interpret screening mammogram
On June 15, 2018, a 43-year-old woman came to an imaging center on referral from Family Physician A for a bilateral screening mammogram. The woman had been Family Physician A’s patient for six months. She had a history of hip pain and scoliosis, with chronic pain throughout her spine.
Failure to properly interpret screening mammogram
On June 15, 2018, a 43-year-old woman came to an imaging center on referral from Family Physician A for a bilateral screening mammogram. The woman had been Family Physician A’s patient for six months. She had a history of hip pain and scoliosis, with chronic pain throughout her spine.
Presentation
On June 15, 2018, a 43-year-old woman came to an imaging center on referral from Family Physician A for a bilateral screening mammogram. The woman had been Family Physician A’s patient for six months. She had a history of hip pain and scoliosis, with chronic pain throughout her spine.
Physician action
On the radiology intake, there was a notation of density of the patient’s outer right breast. Radiologist A interpreted the mammogram as “negative mammogram.”
The patient went to Ob-gyn A on August 25 as a new patient for her annual pap smear. Ob-gyn A noted the patient’s June 15 mammogram was reported as normal. She documented a breast exam with “no lumps/mass, no pain, no redness, or nipple discharge, but noted the patient had fibrocystic changes to both breasts.”
From October 2018 through September 2019, the patient was seen at Family Physician A’s practice 10 times for allergies, shoulder pain, and knee pain. At seven of these visits, a breast exam was noted to be “negative for atypical moles, dry skin, pruritus, rashes, breast masses, and nipple discharge.”
During an October 2019 visit with Family Physician A, the patient was referred to the same imaging center for another routine bilateral screening mammogram. The order for the mammogram indicated the patient had masses to her right outer breast. The radiology intake documentation included a drawing of an area of density at the right outer breast.
The mammogram occurred on October 4. Radiologist A did not see the questionnaire/intake form and reported only looking at the mammogram images. His impression was “[n]egative mammogram. No change.”
That day, the patient had an appointment for a well-woman exam with Ob-gyn A. At this appointment, the patient reported a family history of breast cancer. Ob-gyn A examined the patient and noted “breasts: patient with 2 cm right lateral mass that appears to be fibroadenoma vs. fibrocystic. Remainder of breast tissue is normal.” Ob-gyn A recommended a mammogram, which had already been completed that day at the request of Family Physician A.
The patient had five more visits with Family Physician A’s practice from November 2019 to September 2020. There were no reports of any issues or abnormalities related to the patient’s breasts during this time.
During her 2020 annual exam with Family Physician A, she was referred to the same imaging center for an annual bilateral screening mammogram.
The mammogram occurred on October 9, 2020, and was reviewed by Radiologist B. His impression was “BIRADS Category 2; benign findings and recommend once-year follow-up.” He also noted “there are multiple stable grouped rounded calcifications in the deep upper outer quadrant of the right breast. There are no suspicious forms.”
The patient sought treatment with a new provider, Ob-gyn B, in January 2021. The patient reported a palpable right breast mass, described in the record as “right breast for a couple of years now. Has now started to cause her pain. Concerned with palpable mass and negative mammogram.”
Ob-gyn B’s exam revealed a “2-3 cm upper outer, firm, non-tender, and nipple changes” in the right breast. She referred the patient for a bilateral breast ultrasound and to a general surgeon for further evaluation.
Three days later the patient went to a cancer treatment facility for evaluation of a right breast mass and nipple retraction. The patient reported to the oncologist that one clinician had palpated the mass a year ago and had commented about axillary lymph node, but no additional testing was completed.
A biopsy of the right breast mass revealed invasive ductal cancer, suspicious for multicentric disease and axillary involvement. Though the patient had a good response to chemotherapy, it did not resolve the masses in her right breast. She had a right total mastectomy in August 2021.
Allegations
A lawsuit was filed against Radiologists A and B.
The allegations against Radiologist A included negligence in his interpretation of the June 2018 and October 2019 screening mammograms. Allegations against Radiologist B included negligence in his interpretation of the October 2020 screening mammogram and failure to recommend a diagnostic mammogram or biopsy.
The plaintiffs also alleged that the misreads and failure of both radiologists to diagnose breast cancer resulted in a delay in treatment and reduced the patient’s chance of survival.
Ob-gyn A was also named in the lawsuit.
Legal implications
Radiologists who reviewed this case for both the plaintiff and the defense stated that the screening mammogram from June 2018 showed abnormal and asymmetric micro-calcifications in the upper quadrant of the right breast in both the mediolateral oblique and craniocaudal views. Based on this finding, they felt Radiologist A should have recommended a diagnostic mammogram or breast ultrasound.
These same calcifications were visible on the October 2019 mammogram, but the 1 cm group had grown to 1.4 cm, along with two new masses measuring 0.40 cm and 1.0 cm. According to the reviewers, this finding was suggestive of cancer and further diagnostic testing — including an immediate diagnostic mammogram, ultrasound, or spot compression views — was warranted.
Reviewers were also critical of Radiologist B’s interpretation of the October 2020 mammogram. The 1.4 cm calcification in the 2019 mammogram had increased to 2.2 cm along with a 3.3 cm group in the interior dimension, and a new group measuring 4.0 cm. Because he did not recommend any further diagnostic work up for the patient, the reviewers stated that Radiologist B did not meet the standard of care.
Several of the radiologists reviewing this case also pointed out that the patient questionnaire forms submitted with the orders for the screening mammograms indicated the patient had abnormalities in the right breast. These forms were available to both Radiologists A and B. The plaintiffs argued that based on the abnormalities described in these forms, a diagnostic mammogram or ultrasound “would have diagnosed breast cancer in 2018 or 2019, and certainly in 2020.”
An oncologist who reviewed this case for the plaintiff stated that the delay in diagnosis resulted in the patient having a mastectomy instead of a lumpectomy, and in her receiving chemotherapy instead of only hormone therapy.
This case was also complicated by a lack of follow up from the patient’s ob-gyn. Ob-gyn A — who first treated the patient in 2018 — documented fibrocystic changes to both breasts in 2019. Yet she did not recommend any further testing because she assumed Family Physician A (who ordered the mammograms) was managing the patient’s mammograms and was responsible for ordering appropriate tests.
Disposition
This case was settled on behalf of Radiologist A and B. The outcome of the case against Ob-gyn A is unknown.
Risk management for radiologists
About diagnostic errors
Disclaimer
Presentation
On June 15, 2018, a 43-year-old woman came to an imaging center on referral from Family Physician A for a bilateral screening mammogram. The woman had been Family Physician A’s patient for six months. She had a history of hip pain and scoliosis, with chronic pain throughout her spine.
Physician action
On the radiology intake, there was a notation of density of the patient’s outer right breast. Radiologist A interpreted the mammogram as “negative mammogram.”
The patient went to Ob-gyn A on August 25 as a new patient for her annual pap smear. Ob-gyn A noted the patient’s June 15 mammogram was reported as normal. She documented a breast exam with “no lumps/mass, no pain, no redness, or nipple discharge, but noted the patient had fibrocystic changes to both breasts.”
From October 2018 through September 2019, the patient was seen at Family Physician A’s practice 10 times for allergies, shoulder pain, and knee pain. At seven of these visits, a breast exam was noted to be “negative for atypical moles, dry skin, pruritus, rashes, breast masses, and nipple discharge.”
During an October 2019 visit with Family Physician A, the patient was referred to the same imaging center for another routine bilateral screening mammogram. The order for the mammogram indicated the patient had masses to her right outer breast. The radiology intake documentation included a drawing of an area of density at the right outer breast.
The mammogram occurred on October 4. Radiologist A did not see the questionnaire/intake form and reported only looking at the mammogram images. His impression was “[n]egative mammogram. No change.”
That day, the patient had an appointment for a well-woman exam with Ob-gyn A. At this appointment, the patient reported a family history of breast cancer. Ob-gyn A examined the patient and noted “breasts: patient with 2 cm right lateral mass that appears to be fibroadenoma vs. fibrocystic. Remainder of breast tissue is normal.” Ob-gyn A recommended a mammogram, which had already been completed that day at the request of Family Physician A.
The patient had five more visits with Family Physician A’s practice from November 2019 to September 2020. There were no reports of any issues or abnormalities related to the patient’s breasts during this time.
During her 2020 annual exam with Family Physician A, she was referred to the same imaging center for an annual bilateral screening mammogram.
The mammogram occurred on October 9, 2020, and was reviewed by Radiologist B. His impression was “BIRADS Category 2; benign findings and recommend once-year follow-up.” He also noted “there are multiple stable grouped rounded calcifications in the deep upper outer quadrant of the right breast. There are no suspicious forms.”
The patient sought treatment with a new provider, Ob-gyn B, in January 2021. The patient reported a palpable right breast mass, described in the record as “right breast for a couple of years now. Has now started to cause her pain. Concerned with palpable mass and negative mammogram.”
Ob-gyn B’s exam revealed a “2-3 cm upper outer, firm, non-tender, and nipple changes” in the right breast. She referred the patient for a bilateral breast ultrasound and to a general surgeon for further evaluation.
Three days later the patient went to a cancer treatment facility for evaluation of a right breast mass and nipple retraction. The patient reported to the oncologist that one clinician had palpated the mass a year ago and had commented about axillary lymph node, but no additional testing was completed.
A biopsy of the right breast mass revealed invasive ductal cancer, suspicious for multicentric disease and axillary involvement. Though the patient had a good response to chemotherapy, it did not resolve the masses in her right breast. She had a right total mastectomy in August 2021.
Allegations
A lawsuit was filed against Radiologists A and B.
The allegations against Radiologist A included negligence in his interpretation of the June 2018 and October 2019 screening mammograms. Allegations against Radiologist B included negligence in his interpretation of the October 2020 screening mammogram and failure to recommend a diagnostic mammogram or biopsy.
The plaintiffs also alleged that the misreads and failure of both radiologists to diagnose breast cancer resulted in a delay in treatment and reduced the patient’s chance of survival.
Ob-gyn A was also named in the lawsuit.
Legal implications
Radiologists who reviewed this case for both the plaintiff and the defense stated that the screening mammogram from June 2018 showed abnormal and asymmetric micro-calcifications in the upper quadrant of the right breast in both the mediolateral oblique and craniocaudal views. Based on this finding, they felt Radiologist A should have recommended a diagnostic mammogram or breast ultrasound.
These same calcifications were visible on the October 2019 mammogram, but the 1 cm group had grown to 1.4 cm, along with two new masses measuring 0.40 cm and 1.0 cm. According to the reviewers, this finding was suggestive of cancer and further diagnostic testing — including an immediate diagnostic mammogram, ultrasound, or spot compression views — was warranted.
Reviewers were also critical of Radiologist B’s interpretation of the October 2020 mammogram. The 1.4 cm calcification in the 2019 mammogram had increased to 2.2 cm along with a 3.3 cm group in the interior dimension, and a new group measuring 4.0 cm. Because he did not recommend any further diagnostic work up for the patient, the reviewers stated that Radiologist B did not meet the standard of care.
Several of the radiologists reviewing this case also pointed out that the patient questionnaire forms submitted with the orders for the screening mammograms indicated the patient had abnormalities in the right breast. These forms were available to both Radiologists A and B. The plaintiffs argued that based on the abnormalities described in these forms, a diagnostic mammogram or ultrasound “would have diagnosed breast cancer in 2018 or 2019, and certainly in 2020.”
An oncologist who reviewed this case for the plaintiff stated that the delay in diagnosis resulted in the patient having a mastectomy instead of a lumpectomy, and in her receiving chemotherapy instead of only hormone therapy.
This case was also complicated by a lack of follow up from the patient’s ob-gyn. Ob-gyn A — who first treated the patient in 2018 — documented fibrocystic changes to both breasts in 2019. Yet she did not recommend any further testing because she assumed Family Physician A (who ordered the mammograms) was managing the patient’s mammograms and was responsible for ordering appropriate tests.
Disposition
This case was settled on behalf of Radiologist A and B. The outcome of the case against Ob-gyn A is unknown.
Risk management for radiologists
About diagnostic errors
Disclaimer
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