Case in Point III. A Collection of Closed Claims Focusing on Diagnostic Errors
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1 Case in Point III A Collection of Closed Claims Focusing on Diagnostic Errors
2 Case in Point III A Collection of Closed Claims Focusing on Diagnostic Errors Case in Point III Contributors/Editors Beth Atwell John Franklin Megan Ix Cheryl Matricciani Jaime Meier Gail Sconing Christopher Seiler Elizabeth Svoysky This publication is presented by MEDICAL MUTUAL Liability Insurance Society of Maryland/Professionals Advocate Insurance Company as an educational activity for its policyholders. Nothing contained in this publication is to be considered as the rendering of legal advice for specific cases, and readers are responsible for obtaining such advice from their own legal counsel. This publication is intended for educational and informational purposes only. MEDICAL MUTUAL. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the publisher.
3 1 CASE IN POINT III Treat the patient, not the X-ray. - James M. Hunter This case highlights the potential risks of relying on reports or another physician s diagnosis, even when symptoms or other clinical signs may be inconsistent with those findings. The Case At 7:15 a.m. on December 25, a 45-year-old man arrived at the emergency department of a local hospital complaining of difficulty urinating for the past four days. He stated that he had a long history of constipation, and his recent urinary problems included difficulty starting urination. He denied any burning. Vital signs were normal at BP 158/97, P 98, RR 20, T 99.1, 98% RA, and urinalysis showed trace amounts of blood and protein. A KUB was ordered and the report indicated that there was stool throughout the colon, without evidence of obstruction, renal, or ureteral calculi. The patient was given Flomax.4 mg and a Fleet enema. Before discharge at 10:45 a.m., he was able to move his bowels and had normal urinary flow. Discharge instructions included follow-up with his PCP and a gastroenterologist. The diagnosis was urinary retention secondary to constipation and anal fissure. On December 27, the patient presented to the ED of a different hospital with complaints of difficulty urinating, with pain reported at 10/10. Vital signs were BP 151/89, P 124, RR 20, T 101.8, O2 99% RA. Blood work results were WBC 16.6, chloride 96, anion gap 17. Urinalysis was negative for leukocytes, nitrates, blood, ketones, bilirubin, and glucose. The ED physician ordered a Foley catheter insertion that resulted in output of 1200 cc. The patient s vital signs returned to normal and his pain level was reported at 0/10. He was discharged with the Foley catheter in place, was given a prescription for 500 mg daily of Cipro, and was instructed to return to the ED in two days. The discharge diagnosis was urinary tract infection and urinary retention. On December 29, the patient returned to the second ED just before 1:00 a.m., again complaining of difficulty urinating and reported a new complaint of abdominal pain. The Foley was in place, and on physical exam the patient had supra pubic tenderness. Vital signs CASE IN POINT III n 9
4 CASE 1 were BP 137/81, P 126, RR 22, T 101.2, O2 94% RA. Blood work results included WBC of 22.6, and the urinalysis showed >300 mg/dl protein, a large amount of blood, trace ketones, and a small amount of bilirubin. The bloodwork was negative for leukocytes, nitrate, and glucose. Rocephin 1 gm IV and Dilaudid 1 mg for pain were given. A CT with contrast of the abdomen and pelvis was ordered and interpreted as: normal with non-specific bowel gas pattern and no obstruction. Incidental findings included urinary bladder wall thickening, normal appendix and gall bladder, minimal bilateral renal ureteral distension but no stones, fatty liver, and a left renal cyst. The wet read was reported to the ED, and the CT was re-read several hours later with the same interpretation. The ED physician s diagnosis was UTI, with fever and abdominal pain. The ED physician had the patient admitted to the service of a hospitalist. Vital signs at the time of discharge from the ED were BP 143/68, P 114, RR 18, T 101.3, O2 97% RA. Once admitted at 11:13 a.m., the hospitalist continued IV Rocephin (1 gm IV daily), Tylenol for fever, Dilaudid for pain, and Clonidine for hypertension. A physical exam at 6:00 p.m. that day was unremarkable and the patient denied fever, chills, or chest pain. The patient stated that he had not experienced any change in bowel habits, only difficulty urinating. The notes indicate that the abdomen was soft, nontender, and that bowel sounds were present. The hospitalist s plan included continuing the IV antibiotics and obtaining a renal sonogram and urology consult. At 11:50 p.m. the patient received 1 mg IV Dilaudid for his reported 10/10 pain. Toward the end of the day on December 30, the sonogram was obtained and the report stated that there was bilateral hydronephrosis with no fluid present. A urologist was consulted on December 31. A physical exam was normal except for a mildly enlarged prostate. The urologist s impression was acute urinary retention and he recommended a treatment plan that included continuation of the Foley catheter, Rocephin, Flomax, and evaluation with a cystoscopy at some point. On January 1, the patient s Dilaudid dose was increased from 2 mg to 3 mg for continued reported pain of 10/10. A follow-up renal ultrasound showed no changes from the December 30 study. On January 2, the Foley was removed, but was reinserted after the patient was unable to void. The patient continued to report pain at 9/10, despite 3 mg IV Dilaudid. The patient s WBC was 17.2 and the diagnosis was bilateral pyelonephritis and bilateral hydronephrosis. On January 3, a STAT KUB and stool culture were ordered after the patient passed a moderate amount of bloody stool. He had abdominal pain and tightness and a temperature of 100. The KUB showed multiple distended loops of large and small bowel with air and fecal debris in the rectosigmoid region. The KUB report was dictated at 12:06 p.m. and placed in the patient s medical record. The patient s WBC was 18.9, and Dilaudid at 3 mg IV was continued for reported 9/10 pain. At 8:00 p.m. a nurse noted that the patient had blood coming from the rectal area. 10 n CASE IN POINT III
5 CASE 1 On January 4, the house officer noted for the first time the KUB results, and discontinued the Rocephin and started the patient on Cipro 400 mg IV bid and Flagyl 500 mg IV every 6 hours. The physician immediately ordered a NG tube and a small bowel series. Later that day, the small bowel series was performed with contrast, and multiple distended loops of large and small bowel with evidence of a small bowel obstruction were noted. Approximately 20 hours following contrast administration, contrast was identified in the distal jejunum/proximal ileum, but not in the colon. During the 20 hours there was no evidence that the radiology department notified the House Officer of the unusual duration of the small bowel series. The patient was given Morphine (2 mg) for reported 10/10 pain. Early on January 5, over 150 cc of bile colored drainage was suctioned from the NG tube, and it was reported that the patient had no bowel sounds present. A cystometrogram and cystoscopy were performed by the urologist. There was extreme angulation at the prostatic urethra and the ureteral orifices could not be visualized. A CT was ordered which showed air in the abdomen consistent with a perforation, probable pneumatosis intestinalis in the ascending and descending colon, right perirectal air and fatty stranding, multiple distended loops of large and small bowel, and air and fecal debris in the rectosigmoid region. An emergency surgical consult was obtained. The patient was in septic shock and was taken to surgery where a perforated bowel was found with heavy contamination of the peritoneal cavity with stool. There were three areas of perforation cecum, ascending colon, and extensive laceration of the rectosigmoid. A colostomy, right hemicolectomy, and repair of the rectosigmoid were performed. The post-operative diagnosis was pseudomembranous colitis involving the cecum and ascending colon. The patient was maintained on vasopressors and broad-spectrum antibiotics. He was transferred to a tertiary care center where he underwent additional procedures including a partial proctectomy, partial colectomy, repair of a laceration of the rectal stump, and repair of anastomotic leaks. The patient had numerous complications and was discharged to a rehabilitation facility where he was treated for a colovesical fistula and recurrent UTIs. A nephrostomy tube and ureteral stents were placed. Thereafter, the patient had extensive continued care including surgeries to repair an anastomotic leak, peritonitis, placement of bilateral nephrostomy tubes, persistent colovesical fistulas, continued Foley catheter use, repeat infections, and pressure sores. He was eventually discharged to home. The Analysis The patient filed suit alleging that the health care providers failed to diagnose pseudomembranous colitis resulting in multiple bowel perforations, peritonitis, and the need for nephrostomy tubes. According to the plaintiff, the delay in diagnosis caused colovesical fistulas, Foley catheter use, repeat infections, and pressure sores. The criticism began with the interpretation of the abdominal/pelvic CT scan performed during the initial ED visit on December 29. On re-read, the scan was suspicious for an CASE IN POINT III n 11
6 CASE 1 abscess. Other health care providers relied on the normal interpretation. Should they have questioned the interpretation in light of the patient s continued severe pain? Next, the plaintiff criticized the hospitalist who admitted him after the second ED visit. This physician placed orders for a urine culture, renal and bladder sonograms, and a urology consult. In retrospect, this physician set the course for treatment for a UTI infection when some of the clinical signs and lab results were not consistent with a UTI. The care was turned over to another hospitalist who continued the treatment plan. The records do not reflect that any of the health care providers appreciated or responded to the patient s continued pain complaints, which arguably were inconsistent with a UTI. The KUB and small bowel series on January 3 and 4, respectively, showed possible free air. In light of the patient s clinical condition, a CT should have been recommended. When the surgeon was contacted he recognized the need for emergency surgery and repaired the perforations and lacerations and performed a Hartman s procedure. Unfortunately, the anastomoses leaked. The surgeon was criticized for not performing a colectomy, and for waiting too long to transfer the patient after deterioration was noted. KEY POINTS The treating health care providers had the right to rely on the radiology reports. If symptoms continue and are inconsistent with the radiology report, consider taking another look at the radiology studies. Once a diagnosis has been made and treatment begun, don t blindly follow the plan. Consider all information and question whether the diagnosis is correct. Differential diagnosis should be part of every treatment plan. A wellthought-out differential diagnosis encourages consideration of other possible causes of the patient s condition. Communication, particularly among specialists, can encourage a broad discussion of the patient instead of single specialty treatment. 12 n CASE IN POINT III
7 Thank you for your interest in Case in Point III! Interested in reading more? Click here to register online and order Case in Point III today! The fee for Case in Point III is $50 PER PERSON. Participants will receive a copy of the Case in Point III book by mail. To satisfy the requirements of the course, participants must read the book and complete a short post-test at the conclusion. Participants will also be asked to complete an evaluation form. The finished post-test and evaluation form should be sent back to MEDICAL MUTUAL/Professionals Advocate in the postage-paid envelope included with the book. Participants who successfully complete this course will receive the same 5% premium discount that they would receive for attending a live activity. Registrations for Case in Point III must be received by August 19, Completed tests and evaluations are due no later than September 23, For additional information on Case in Point III, contact our Risk Management Services Department at or (toll free).
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