Delay in the diagnosis of lung cancer

Presentation

A 62-year-old man came to his family physician’s office reporting weakness in his arms and legs. The patient had been under the care of this physician for three years and had a history of diabetes and hypertension. The medical records indicated he did not smoke or drink. The family physician referred the patient to a local emergency department (ED).

Physician action

The ED physician suspected a stroke, and the patient was admitted under the care of a neurologist, the defendant in this case. The patient had suffered a cerebral infarction that resulted in left-sided hemiplegia.

The neurologist evaluated the patient and found there were no x-ray reports in the chart. He initiated medical therapy for the stroke and ordered a chest x-ray if one had not already been done.

The next morning, the neurologist examined the patient and reviewed his chart. The chart now included a chest x-ray report describing an ill-defined infiltrate of the right lobe and recommended a follow-up study. The neurologist further reviewed the chart and found a second chest x-ray report, this one describing a clear field.

The neurologist was satisfied with the lung assessment, and concluded that the second chest x-ray report was the one he had ordered. He was not surprised by the appearance of a second chest film report, even though he had not specifically ordered a follow-up chest film.

The neurologist assumed the ward clerk or nurse was unaware of the original film and obtained a second in response to his written order to obtain a chest x-ray if one had not been done. The neurologist made reference to the second chest film in his discharge summary.

After six days in the hospital, the patient was discharged to a rehabilitation facility. The patient recovered use of his left leg, but continued to have paralysis in the left arm. He required speech, physical, and occupational therapy.

Approximately 18 months after the stroke, the patient developed a cough and difficulty breathing. A chest x-ray revealed a moderate-sized right pleural effusion. He underwent a thoracentesis with withdrawal of more than one liter of bloody fluid.

A second procedure a month later led to a pathological evaluation for suspicion of malignancy. The patient was found to have a soft tissue mass of 2.2 cm, confirmed to be a metastatic adenocarcinoma consistent with the lung as the primary site. The patient underwent chemotherapy, but died one year later.
 

Allegations

In their lawsuit against the neurologist and the hospital, the patient’s family alleged delay in the diagnosis of lung cancer. Learning that the lawsuit involved lung cancer, the neurologist reviewed a copy of the patient’s hospital record, and learned for the first time that the follow-up chest x-ray that showed a clear lung field referred to a different patient.
 

Legal implications

It was clear that the neurologist relied on the “clear lung field” report of a different patient and did not resolve the suspicion raised by the first x-ray. The plaintiff’s oncology expert claimed that the cancer was either stage I or early stage II at the time of the hospital x-ray with a probable five-year survival rate of 30%. When the correct diagnosis was made, the patient’s five-year survival rate was less than 1%.

The plaintiff’s neurology expert testified that the defendant breached the standard of care by failing to recognize the name on the x-ray report was not his patient’s. However, he also testified that when a physician picks up a hospital chart, it is reasonable to anticipate that the documents in the chart belong to that patient. He agreed that the vast majority of reports found in medical charts are properly filed.

At his deposition, the defense neurology expert testified that while not favorable, the wrong report can make it into a physician’s hands unnoticed without the physician being negligent. All defense consultants who reviewed the medical records in this case failed to catch the misfiled x-ray report, as did the other physicians who treated the patient in the hospital.

This case was further complicated by a conflict with the codefendant hospital over responsibility for the error. The hospital staff testified that it was the physician’s duty to verify that each report in the chart was for that patient.

Disposition

This case was settled on behalf of the neurologist and the hospital.

Risk management considerations

It was easily argued by the plaintiff that responsibility was shared in the events of this case. In fact, the hospital employees testified that the reason documents contain the names of patients is so readers can verify that they are reading the information on that particular patient.

Physicians, on the other hand, may believe that they have a right to rely on the hospital staff to appropriately file documents in the correct charts. They must be able to rely on support staff.

When reviewing charts, it is common for physicians to focus on the diagnosis section of lab and test reports. In this particular record, had the physician read the entire report, he might have noticed that some elements of the description did not fit this patient, not to mention that the name at the top was of a different patient. In fact, the plaintiffs pointed that out in testimony, and it was an obstacle to a successful defense.

Physicians may be well advised to take the extra step of scanning reports in full when reviewing charts. Likewise, the hospital has hopefully examined its procedures and staff responsibilities to prevent this type of error from occurring again.