Medical Malpractice Insights: Radiology over-reads – Who’s responsible?

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Chuck Pilcher, MD, FACEP

Editor, Medical Malpractice Insights

Editor, Med Mal Insights

Radiology over-reads – Who’s responsible?

Patient not informed of enlarged heart, dies 3 weeks post ED visit

Miscommunicated radiology findings are a hot topic. Who is responsible for notifying patients of post discharge findings? What role do discharge instructions play? Do they establish a standard of care? This story, while unlikely to reflect the standards of most readers, has a somewhat surprising outcome.

Facts: A 52-year-old, 377-pound hypertensive male presents to the ED with a 1 day history of chest and abdominal pain that started while working on a deck at home. EKG, labs, and a CXR are interpreted by the EP as normal. He is diagnosed with “chest wall pain” and discharged with instructions to see his PCP in 2-3 days. He is allegedly told – and his DC instructions state – that his CXR will be reviewed by a radiologist and that he will be notified of any changes in the reading. The radiologist finds significant cardiomegaly and sends a report to both the ED and the patient’s PCP. An unknown EP reviews the report, determines that there is no reason to notify the patient, and documents nothing. The patient does not see his PCP as recommended and dies 24 days later of a suspected cardiac arrhythmia. Autopsy shows coronary atherosclerosis and marked cardiomegaly with a thickened left ventricular wall. An attorney is consulted and a lawsuit filed against the hospital, the first ED physician, the EM group, and the PCP.

Plaintiff: You told me you would call me if the radiology report was “different.” My discharge instructions actually said that – but you never called me. Someone should have – either the first ED doc, the second ED doc, or my PCP. I felt better after I left but would have seen my PCP if I had known that my heart was enlarged. Even if we don’t know who the second EP was, he was an agent of the hospital, so the hospital is also liable.

Defense: Cardiomegaly is a chronic problem, not an emergency. You didn’t see your PCP as instructed. Hospital policy is that the on-duty ER doc reviews the radiologist’s report and determines if it’s important enough to change the treatment plan. It wasn’t, so you weren’t called, nor did the doc need to document anything. Our expert says that (in this specific case) the failure to call the patient was not a breach of the standard of care, despite what the discharge instructions said.

Result: Defense verdict, affirmed on appeal, stating that “the failure to call was a breach of the discharge instructions… not the standard of care.”

Takeaways:

1. This jury found that discharge instructions do not establish a standard of care, but don’t count on it. Jurisdictions and juries differ.
2. Pay attention when a patient is being seen for exertional chest pain.
3. Always consider aortic dissection when the pain is also abdominal.
4. This patient’s history was either poorly taken or poorly documented.
5. Too much weight was given to the EKG, CXR, and labs.
6. Poorly communicated incidental post-discharge findings or lab results commonly lead to med mal lawsuits.
7. Be sure your department(s) and hospital have a solid communication procedure for situations like this, especially if 24-hour radiology readings are not available.

Thankfully, this communication problem is being addressed, especially by radiologists who recognize the need to be more pro-active in assuring that patients know the final results of their imaging.

References:

1. System-Level Process Change Improves Communication and Follow-Up for Emergency Department Patients With Incidental Radiology Findings. Baccei SJ et al. J Am Coll Rad 15:4;639-647, April 1, 2018.
2. Catching Those Who Fall Through the Cracks: Integrating a Follow-Up Process for Emergency Department Patients with Incidental Radiologic Findings. Tyler W et al. Ann. Emerg. Med. Volume 80, no. 3 : September 2022.