by Sara Bergmanson, Digital and Social Media Specialist and
Wayne Wenske, Strategic Marketing Specialist
Presentation and physician action
A 68-year-old man saw Orthopedic Surgeon A over several months for pain in his right knee, leg, and lower back. Right knee arthroscopic surgery was recommended and scheduled.
On November 12, 2017 a preoperative chest x-ray (CXR) was performed. Radiologist A interpreted the x-ray and found a 3.3 cm mass and noted “neoplasm is the diagnosis of exclusion.” Radiologist A called but did not speak with Orthopedic Surgeon A; instead, he left a call back number to discuss results. Orthopedic Surgeon A did not recall speaking with the radiologist when later discussing the case.
The CXR report was faxed to the patient’s primary care physician (Primary Care Physician A) on November 15. The cover page for the fax read, “Please review abnormal CXR, and radiologist recommends CT of chest.”
On November 16, Orthopedic Surgeon A performed arthroscopic surgery on the patient’s right knee. Over the next eight months, the patient returned to Orthopedic Surgeon A for follow-up visits and continued right knee pain.
On February 8, 2018, the patient saw Primary Care Physician A for an annual medical exam. Primary Care Physician A did not mention the CXR; however, he documented during the visit that a CXR was performed in September 2010 and had a calcium score of 442. It was later discovered that the 2017 CXR report describing the lung mass was in the patient’s chart at the time of this visit.
In June, Orthopedic Surgeon A referred the patient to Orthopedic Surgeon B, a partner within the orthopedic group, to rule out right leg pain secondary to right lumbar radiculopathy. Orthopedic Surgeon B and a neurologist diagnosed the right leg pain as primarily from right hip osteoarthritis.
A week later, the patient returned to Primary Care Physician A for a routine exam. There was no mention of the 2017 CXR.
The patient saw Orthopedic Surgeon A again in July for hip pain and was given an injection. Orthopedic Surgeon A and the patient discussed hip replacement and scheduled the surgery for October. Primary Care Physician A cleared the patient for surgery in September.
Orthopedic Surgeon A ordered a preoperative CXR, which was completed on October 12, 2018. Radiologist B noted that when compared to the x-ray performed in November 2017, the mass had enlarged to 5 x 5.2 cm. The x-ray findings were faxed to Orthopedic Surgeon A.
On October 15, a chest CT confirmed the left upper lobe mass, and an incidental right renal lesion was also found. The patient was referred to a pulmonologist for biopsies, and the results revealed squamous cell carcinoma in the left upper lobe.
On November 14, the patient underwent a left upper lobectomy and later completed chemotherapy. He was staged as a T3N1; IIIA.
The patient is in remission and has had no further issues since treatment. The hip replacement was completed the following year by another orthopedic surgeon in the same group as Orthopedic Surgeons A and B.
A lawsuit was filed against Orthopedic Surgeon A and the orthopedic group. The patient alleged he would not have progressed to stage III cancer or needed chemotherapy had Orthopedic Surgeon A properly communicated the lung mass discovered on November 12, 2017. This caused a one-year delay in diagnosis leading to more extensive treatment and a heightened probability of a shortened life expectancy.
Consultants for the defense were not supportive of Orthopedic Surgeon A, stating it was his responsibility to follow up with the pre-operative CXR and to directly communicate x-ray results to the patient and Primary Care Physician A. There is no documentation that Orthopedic Surgeon A ever read or followed up on the results before performing knee surgery on November 16, 2017. Orthopedic Surgeon A saw the patient eight times for post-surgery follow up and never mentioned the x-ray findings.
According to the consultants reviewing the case, the delay in reporting the findings had an adverse effect on the patient, increasing the growth of lung cancer and metastatic disease, ultimately shortening the patient’s life expectancy after five years.
The orthopedic group, Primary Care Physician A, and the anesthesiologist from the knee surgery were also criticized for not acting upon the findings. It was discovered that the orthopedic group did not have policies and procedures in place for alerting physicians or patients of emergent test results.
Primary Care Physician A did not see the x-ray report during two appointments despite it being in the patient’s chart. The anesthesiologist had seen the findings before providing anesthesia services and also did not inform the patient.
The case was settled on behalf of Orthopedic Surgeon A and the orthopedic group.
Risk management considerations
As this case illustrates, having written policies and procedures in place to track and follow up with lab work, testing, and referrals is important for quality patient care. Maintaining standardized policies and procedures helps to ensure that each care team member understands their responsibilities. In this case, the chest x-ray results were emergent, but the physicians did not respond appropriately.
While a physician who orders diagnostic testing or imaging is ultimately responsible for obtaining the results and acting on them, there is also a shared responsibility of all physicians to ensure results are communicated in a timely manner. This includes timely review and reporting of critical results to patients and planning appropriate follow up.
Radiologist A left a voicemail message for Orthopedic Surgeon A and faxed the results to Primary Care Physician A without following up to ensure they received and understood the test results. Both physicians later testified that they were unaware of these communications.
It is important to create, implement, and maintain tracking policies and procedures, with special consideration made to critical, unexpected or abnormal results. In this case, a communication breakdown occurred after the results were received. They were sent to the practice, and additional communication attempts were made by the radiologist. However, the results were not reviewed by treating physicians or communicated to the patient.
For the provider performing or interpreting the ordered test — in this case, the radiologist — it is recommended to document the specifics of communication efforts. If attempts to reach the ordering physician are unsuccessful and critical results are communicated to the ordering physician’s staff member, including the staff member’s full name, credentials, and date and time of communication in the medical record and/or report is recommended.
According to the American College of Radiology, there are also instances when it may be appropriate for an interpreting physician to contact the patient directly with results if the ordering physician cannot be located or reached. (1)
Whenever policies and procedures are updated or changed, changes should be communicated to all employees. Staffs members should then be instructed to sign and date the new policies and procedures as an acknowledgement that they have read and understood the updates. This also acknowledges their understanding of any changes to their individual roles and responsibilities.
- American College of Radiology. ACR Practice Parameter for Communication of Diagnostic Imaging Findings. Available at https://www.acr.org/-/media/ACR/Files/Practice-Parameters/CommunicationDiag.pdf. Accessed June 4, 2021.
Sara Bergmanson can be reached at firstname.lastname@example.org.
Wayne Wenske can be reached at email@example.com.