Failure to report misplaced central line

July 3, 2019

Presentation
On July 22, a 64-year-old woman came to the emergency department (ED) of a local hospital. The patient had undergone back surgery five days earlier, and she came to the ED for a possible accidental overdose of pain medication. She exhibited signs of altered mental status, acting differently, and trouble concentrating. 

The patient’s history included COPD, hypertension, congestive heart failure, obstructive sleep apnea, and chronic lower back pain. Her vital signs were blood pressure 70/40 mm Hg; pulse 90; respirations 20; and temperature of 99.5 degrees. 

Shortly after arriving in the ED, she vomited a large amount of black coffee emesis. Emergency Physician A intubated the patient and inserted a central line in the right subclavian vein. Hospitalist A admitted the patient to the ICU. 

 

Physician action
Hospitalist A requested a pulmonary consult, and Pulmonologist A saw the patient on July 23. Pulmonologist A reviewed a chest x-ray taken of the patient the day before. He confirmed that the patient had pneumonia. Pulmonologist A’s differential diagnosis was acute respiratory failure, aspiration pneumonia, sepsis related to aspiration, and COPD. 

Pulmonologist A ordered to continue IV fluids and maintain the patient’s central venous pressure (CVP) at 6- to 8- cm of water. At 10 a.m., a nurse contacted Pulmonologist A and told him the patient’s CVP was in the 70s. Pulmonologist A assumed the central line was kinked and could still be used to deliver medication to the patient. Pulmonologist A left the hospital the evening of July 23 and did not return until July 28.

Chest x-rays were taken every day from July 22 to July 28. Radiologist A read the chest films taken on July 22, 27, and 28. He did not mention the central line on July 22, but on the 27 and 28 reports he stated it was uncertain whether the line was in an artery or vein.

Radiologist B read the chest film on July 23 and reported that the catheter tip appeared to be in the right innominate vein. Radiologist C read the chest films from July 24-28. On each of her reports, she recommended the subclavian line be repositioned as the tip of the catheter crossed the midline.

When Pulmonologist A returned on July 28, he reviewed the chest films and thought the tip of the central line was coming out. He ordered a peripherally inserted central catheter (PICC) line. Arterial blood gas measurements confirmed the central line was in the artery, not the subclavian vein as documented.

When the patient’s sedation was lightened in anticipation of a possible extubation, she was found to have weakness and decreased mobility on her left side. The misplaced subclavian line was removed. 

The patient was transferred to a regional hospital, where she was found to have an embolic acute infarct predominantly in the right middle cerebral artery territory, secondary to a misplaced line. 

Upon discharge, the patient had left-sided weakness, no use of her left arm, a left foot drop, and cognitive deficits. She received physical and occupational therapy at a skilled nursing facility. The patient now has left arm hemiparesis, but is reported to be doing well. 

 

Allegations
Lawsuits were filed against Pulmonologist A, Hospitalist A, and Radiologists A, B, and C. The allegations against the radiologists involved failure to diagnose that the central line was in the artery and not a vein, and failure to report their findings to the referring physicians. 

 

Legal implications
Three defense consultants reviewed the care given by the treating radiologists. All of the consultants stated that it was not possible to tell if a catheter is in an arterial or venous system based only on a chest x-ray. Therefore, their interpretations of the x-rays were accurate and met the standard of care.  

The consultants were critical of Emergency Physician A, who placed the line. They indicated that it is fairly easy to determine if the line is in the arterial or venous system at the time of placement. Further, it would have been the attending physician’s responsibility to follow up on placement, not a radiologist’s. 

The main criticism against the radiologists involved their failure to call the treating physicians and emphasize the need to re-check the line placement. However, the treating physicians testified that they were aware of the radiologist reports indicating that the line was not in a good position, but took no action to re-position the line. 

 

Disposition
Though experts testified that the radiologists met the standard of care, there was concern about the potential for an adverse jury verdict. Therefore, this case was settled on behalf of the three radiologists, Pulmonologist A, and Hospitalist A.  

 

Risk management considerations
In non-routine clinical situations, the radiologist should expedite delivery of report findings and communicate directly with the ordering physician. Also, the American College of Radiology’s Guidelines for Communication of Diagnostic Imaging Findings offers instructions for creating a complete diagnostic imaging report. Two guidelines apply in this case:

Clinical issues:  the report should address or answer any specific clinical questions. Factors that prevent answering the clinical questions should be clearly stated.

Impression (conclusion or diagnosis):  follow-up or additional diagnostic studies to clarify or confirm the impression should be suggested when appropriate.

Situations that may warrant non-routine communication include cases that occur in critical care units that involve the findings of a significantly misplaced line or tube. Findings that may affect patient care if not treated in a timely fashion, and are unexpected by the ordering physician, would also fall into this category.

It is a best practice for interpreting physicians to document all non-routine communications in the radiology report with the date, time, method of communication, and name of the person receiving the report. (1)

Unfortunately, when a case involves several physicians, poor communication can be an issue. There are several ways to communicate in today’s electronic age, but having a conversation with the patient’s health care provider and following up by documenting the conversation may provide the radiologist with context for future studies.   

 

Source
1. American College of Radiology. ACR Practice Guidelines for Communication of Diagnostic Imaging Findings. 2014 Revision. Available at https://www.acr.org/~/media/C5D1443C9EA4424AA12477D1AD1D927D.pdf. Accessed May 12, 2017.  

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