healthcare

Failure to communicate and delay in  diagnosing lung cancer 

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.