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Chapter 10 Medical Staff Organization and Malpractice Diagnosis

▸ DIAGNOSIS Medical diagnosis is not always an easy task. Making an accurate diagnosis involves

the process of identifying a patient’s illness. Patient assessments, reassessments,

and test results (e.g., imaging and laboratory studies) are some of the tools of

medicine that assist providers in diagnosing the possible causes of a patient’s

symptoms and medical problems. An accurate diagnosis provides the practitioner

with alternative treatment options. The cases presented here describe a variety of

lawsuits that have occurred due to misdiagnoses.

Failure to Order Diagnostic Tests A plaintiff who claims that a physician failed to order proper diagnostic tests must

show the following:

It is standard practice to use a certain diagnostic test under the circumstances of the

case.

The physician failed to use the test and therefore failed to diagnose the patient’s

illness.

The patient suffered injury as a result.

Ophthalmologist Fails to Order Tests

In Gates v. Jensen, a lawsuit was brought against Dr. Hargiss, an ophthalmologist,

and others for failure to disclose to Mrs. Gates that her test results for glaucoma

were borderline and that her risk of glaucoma was increased considerably by her

high blood pressure and myopia. Hargiss failed to perform a field vision test and to

dilate and examine the eye. He wrote off the patient’s problem of difficulty in

focusing and gaps in vision as being related to difficulties with her contact lenses.

Gates visited the clinic 12 times during the following 2 years with complaints of

blurriness, gaps in her vision, and loss of visual acuity. Gates eventually was

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diagnosed with glaucoma. By the time Gates was properly treated, her vision had

deteriorated from almost 20/20 to 20/200. The court held that a duty of disclosure

to a patient arises whenever a physician becomes aware of an abnormality that may

indicate risk or danger. The facts that must be disclosed are those facts the

physician knows, or should know, of which a patient needs to be aware to make an

informed decision on the course of future medical care.

Once a physician concludes that a particular test is indicated, it should be

performed and evaluated as soon as practicable. Delay may constitute negligence.

The law imposes on a physician the same degree of responsibility in making a

diagnosis as it does in prescribing and administering treatment.

Misdiagnosis of Appendicitis

Failure to order diagnostic tests resulted in the misdiagnosis of appendicitis in

Steeves v. United States.

In this case, physicians failed to order the appropriate diagnostic tests for a child

who was referred to a Navy hospital with a diagnosis of possible appendicitis.

Judgment in this case was entered against the United States, on behalf of the U.S.

Navy, for medical expenses and for pain and suffering. The patient was given a test

that indicated a high white blood cell count. A consultation sheet was given to the

mother, indicating the possible diagnosis. The physician who examined the patient

at the Navy hospital performed no tests, failed to diagnose the patient’s condition,

and sent him home at 5:02 PM, some 32 minutes after his arrival on July 21. The

patient was returned to the emergency department on July 22, at about 2:30 AM,

and was once again sent home by an intern who diagnosed the patient’s condition

as gastroenteritis. No diagnostic tests were ordered. The patient was returned to the

HOW NOT TO BECOME A MEDICAL MYSTERY

No one wants to be a medical mystery. But it’s easy to become one.

While diagnosis may seem straightforward, the process can be surprisingly complex, strewn with cognitive land mines, logistical roadblocks, and red herrings. These complexities—and wrong turns—help create the medical mysteries.

—Tresa Baladas

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Navy hospital on July 23, at which time diagnostic tests were performed. The patient

was subsequently operated on and found to have a ruptured appendix.

Holding the Navy hospital liable for the negligence of the physicians who acted as its

agents, the court pointed out that a wrong diagnosis will not in and of itself support

a verdict of liability in a lawsuit. However, a physician must use ordinary care in

making a diagnosis. Only where a patient is examined adequately is there no liability

for an erroneous diagnosis. In this instance, the physicians’ failure to perform

further laboratory tests the first two times the child was brought to the emergency

department was found to be a breach of good medical practice.

Efficacy of Test Questioned A medical malpractice action was brought against Mambu in Sacks v. Mambu for

failure to make a timely diagnosis of Sacks’s colon cancer. It was alleged that Mambu

was negligent in that he failed to properly screen Sacks for fecal occult blood to

determine whether there was blood in the colon.

Because of complaints of fatigue by the patient, Mambu ordered blood tests that

revealed a normal hemoglobin, the results of which suggested that Sacks had not

been losing blood. However, by late July 1984, Sacks experienced symptoms of

jaundice. Mambu ordered an ultrasound test, and Sacks was subsequently

diagnosed with a tumor of the liver. He was admitted to the hospital and diagnosed

with having colon cancer. By the time the cancer was detected, it had invaded the

wall of the bowel and had metastasized to the liver. Sacks died in March 1985.

The trial court entered judgment on a jury verdict for Mambu, and the plaintiff

appealed. The Pennsylvania Superior Court upheld the decision of the trial court.

The jury determined that the physician’s failure to administer the test had not

increased the risk of harm by allowing the cancer to metastasize to the liver before

discovery and, therefore, was not a substantial factor in causing the patient’s death.

Although the presence of blood in the stool may be suggestive of polyps, cancer,

and a variety of other diseases, not all polyps and cancers bleed. Physicians are

therefore in disagreement as to the efficacy of the test.

In another case, at the age of five the plaintiff began to complain about chest pains

and trouble breathing. The symptoms reported and the initial testing suggested that

the plaintiff either had asthma or cystic fibrosis. Without further testing, the

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plaintiff’s physician reached a diagnosis of cystic fibrosis and ordered treatment

based on that diagnosis. Treatment included daily prescription medication and over

3,000 hours of painful percussion and vibration chest therapy. During percussion

and vibration therapy a machine was used to palpitate the chest of the plaintiff in

order to break up any secretions in the lungs and clear his airways for improved

breathing.

In addition to the treatment, the diagnosis took a psychological toll on the patient.

The patient was told that he would never be able to have children, his life

expectancy was approximately 30 years, and he would eventually have to undergo

lung transplant surgery. When the plaintiff entered his preteen years his parents

began to question the diagnosis and educated themselves on the disease.

After reaching out to the physician multiple times with no response, the parents

decided to get a second opinion from a consulting physician. The consulting

physician ordered a new test specifically to diagnose cystic fibrosis. The new test

came back negative. In the opinion of the consulting physician the plaintiff was

never appropriately tested and did not have cystic fibrosis. In this case the jury

found in favor of the plaintiff, and awarded him $2 million, which was the cap on

medical malpractice damages at the time in Virginia.

Failure to Promptly Review Test Results Can a physician’s failure to promptly review test results be the proximate cause of a

patient’s injuries? The answer is yes. In Smith v. U.S. Department of Veterans Affairs, the plaintiff, Smith, was first diagnosed as having schizophrenia in 1972.

He had been admitted to the Veterans Affairs (VA) hospital psychiatric ward 15 times

since 1972. His admissions grew longer and more frequent as time passed. On the

occasion of his March 17, 1990, admission, he had been drinking in a bar, got into a

fight, and was eventually taken to the VA hospital. Dr. Rizk was assigned as Smith’s

attending physician. Smith developed an acute problem with his respiration and

level of consciousness. It was determined that his psychiatric medications were

responsible for his condition. Some medications were discontinued, and others

were reduced. An improvement in his condition was noted.

By March 23, Smith began to complain of pain in his shoulders and neck. He

attributed the pain to more than 20 years of service as a letter carrier and to

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osteoarthritis. His medical record indicated that he had similar complaints in the

past. A rheumatology consultation was requested and carried out on March 29. The

rheumatology resident conducted an examination and noted that Smith reported

bilateral shoulder pain increasing with activity as an ongoing problem since 1979.

Various tests were ordered, including an erythrocyte sedimentation rate (ESR).

Smith was incontinent and complained of shoulder pain. By the afternoon, he was

out of restraints, walked to the shower, and bathed himself. On returning to his

room, he claimed that he could not get into bed. He was given a pillow and slept on

the floor. By the morning of April 4, Smith was lying on the floor in urine and

complaining of numbness. His failure to move was attributed to his psychosis. By

evening, it was noted that Smith could not lift himself and would not use his hands.

On April 5, a medical student noted that Smith was having difficulty breathing and

called for a pulmonary consultation. By evening, Smith was either unwilling or

unable to grasp a nurse’s hand and continued to complain that his legs would not

hold him up.

On the morning of April 6, Smith was complaining that his neck and back hurt and

that he had no feeling in his legs and feet. Later that day, a medical student noted

that the results of Smith’s ESR was 110 (more than twice the normal rate for a man

his age). His white blood cell count was 18.1, also well above the normal rate. A staff

member noted on the medical record that Smith had been unable to move his

extremities for approximately 5 days. A psychiatric resident noted that Smith had

been incontinent for 3 days and had a fever of 101.1°F.

On the morning of April 7, Smith was taken to University Hospital for magnetic

resonance imaging of his neck. Imaging revealed a mass subsequently identified as

a spinal epidural abscess. By the time it was excised, it had been pressing on his

spinal cord too long for any spinal function to remain below vertebrae 4 and 5.

The plaintiff brought suit alleging that the physicians’ failure to promptly review his

test results was the proximate cause of his paralysis. Following a bench trial, the U.S.

District Court agreed, holding that the negligent failure of physicians to promptly

review laboratory test results was the proximate cause of the plaintiff’s quadriplegia.

Of primary importance was the plaintiff’s ESR of 110; the test results were available

on the patient care unit by April 2 but were not seen, or at least not noted in the

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record, until April 6. An elevated ESR generally accounts for one of three problems:

infection, cancer, or a connective tissue disorder. Most experts agreed that, at the

very least, a repeat ESR should have been ordered. The VA’s care of the plaintiff fell

below the reasonable standard of care in that no one read the laboratory results

until April 6. The fact that the tests were ordered mandates the immediate review of

the results. Although it cannot be known with certainty what would have occurred

had the ESR been read and acted upon on April 2, it is certain that the plaintiff had a

chance to fully recover from his infection. By April 6, that chance was gone.

Due to the absence of notes from Rizk in the plaintiff’s chart, it is impossible to know

whether Rizk was aware of the plaintiff’s symptoms. However, it appears that the

absence of notes by Rizk indicated that Rizk’s care of the plaintiff was negligent, and

the failure to review the lab results constituted negligence under the relevant

standard of care. That led to the failure to make an early diagnosis of the plaintiff’s

epidural abscess, which was the proximate cause of the patient’s eventual paralysis.

It was foreseeable that ignoring a high ESR could lead to serious injury.

A mechanism should be in place to expeditiously notify the patient’s physician of

abnormal test results. Computer systems help ensure physicians are notified of

critical lab data so that appropriate care decisions can be implemented.

Timely Diagnosis A physician can be liable for reducing a patient’s chances for survival. The timely

diagnosis of a patient’s condition is as important as the need to accurately diagnose

a patient’s injury or disease. Failure to do so can constitute malpractice if a patient

suffers injury as a result of such failure.

Failure to Read X-Ray Report

On February 5, 1988, Mr. Griffett was taken to the emergency department with a

complaint of abdominal pain. Two emergency department physicians evaluated

him and ordered X-rays, including a chest X-ray. Dr. Bridges, a radiologist, reviewed

the chest X-ray and noted in his written report that there was an abnormal density

present in the upper lobe of Griffett’s right lung.

Griffett was referred to Dr. Ryan, a gastroenterologist, for follow-up care. Ryan

admitted Griffett to the hospital for a 24-hour period and then discharged him

without having reviewed the radiology report of the February 5 chest X-ray. On

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March 1, 1988, Griffett continued to experience intermittent pain. A nurse in Ryan’s

office suggested that Griffett go to the hospital emergency department if his pain

became persistent.

In November 1989, Dr. Baker examined Griffett, who was complaining of pain in his

right shoulder. Baker diagnosed Griffett’s condition as being cancer of the upper

lobe of his right lung. The abnormal density on the February 5, 1988, chest X-ray was

a cancerous tumor that had doubled in size from the time it had been first

observed. The tumor was surgically removed in February 1990; however, Griffett

died in September 1990.