By Damian D. Capozzola, Esq.
The Law Offices of Damian D. Capozzola
Jamie Terrence, RN
President and Founder, Healthcare Risk Services
Former Director of Risk Management Services
California Hospital Medical Center
Rebeka Rioth, 2017 JD Candidate
Pepperdine University School of Law
News: A woman arrived at the ED of a hospital and was complaining of abdominal pain. ED staff ordered a CT scan of the woman’s lower abdomen. The radiology department reported that the woman’s CT scan indicated a perforated bowel and/or appendix. However, the CT scan that the radiology department reported actually was that of another patient and had been incorrectly labeled as the woman’s CT scan. A surgeon reviewed this mislabeled CT scan and then informed the woman that she needed to undergo immediate, life-saving surgery. Despite the fact that the surgeon could not locate any signs of a perforation in the woman’s abdomen during surgery, he performed an appendectomy. However, the woman continued to suffer from severe and chronic abdominal pain. Months later, hospital representatives informed the woman of the mislabeled CT scan and said that they were unable to locate her CT scan. The woman and her husband sued the hospital. They argued that due to the hospital’s failure to correctly label and identify the woman’s radiology scans, the woman underwent an unnecessary appendectomy that resulted in nerve damage and lost wages. Following a trial, the jury returned a $6 million verdict in favor of the woman and found that the hospital violated its standard of care.
Background: In 2009, a woman went the ED of a hospital due to severe abdominal pain. Her symptoms included vomiting, nausea, fever, coughing, and vaginal bleeding. The on-call physician examined the woman, determined that she had tenderness in the lower right quadrant of her abdomen, and ordered a CT scan. Several hours later, the radiology department informed the ED staff that the woman’s CT scan returned abnormal and displayed extravasation of contrast in the lower pelvis, which indicated a perforated bowel and/or appendix. However, the CT scan that the radiologist reported was a mislabeled CT scan of another patient’s abdomen.
In reviewing this mislabeled CT scan, the radiology department also reviewed the woman’s demographic information, which included past medical history, clinical findings, and a prior CT scan taken in 2007. This demographic information revealed that the woman had undergone a previous cholecystectomy, and the surgical clips used in the procedure could be viewed in the 2007 CT scans. However, the mislabeled CT scan from 2009 displayed a body with an intact gallbladder. The mislabeled CT scan was sent to the ED, where it was reviewed by a surgeon. The surgeon then notified the woman that she would need immediate surgery to save her life.
The woman relied on the surgeon’s statements and agreed to have an exploratory laparotomy, during which the surgeon could not locate any abnormalities in the woman’s abdomen. Despite the fact that the surgeon could not find any perforations or extravasation of contrast, he performed an appendectomy on the woman. Following her surgery, the woman continued to experience chronic and severe abdominal pain around her incision site that worsened with bending.
The woman continued to suffer from severe and chronic abdominal pain following this procedure.
A few months later, the hospital informed the woman that the mislabeled CT scan belonged to another patient and the hospital could not locate the woman’s CT scan. The woman and her husband sued the hospital. They argued that the woman underwent an unnecessary appendectomy due to the hospital’s failure to correctly label the woman’s radiology scans. As a result of the unnecessary procedure, a nerve near the woman’s incision site became entrapped, which caused the woman to experience severe pain when she moved. They also argued that the hospital failed to provide the woman with hospital personnel who could competently identify radiology films. Finally, they argued that the hospital failed to implement adequate policies to ensure that radiology films are properly identified.
The lawyers for the hospital argued that while a hospital employee did mislabel two CT scans, the woman’s chronic abdominal pain is a pre-existing condition that is unrelated to the appendectomy. The attorneys for the hospital also argued that this was an isolated event and that because the hospital had no prior history of problems mislabeling radiology films, the hospital did not have actual or constructive knowledge that their radiology polices and protocols were deficient. After a jury trial, the jury returned a $6 million verdict in favor of the woman and held that the woman’s injuries were caused by the hospital’s failure to adhere to the proper standard of care.
What this means for you: This case illustrates the vital degree of diligence that healthcare providers must practice in the care and treatment of their patients. Patient identification is a National Patient Safety Goal from The Joint Commission. Every hospital employee, including radiology technicians, is trained to use two patient identifiers before performing any procedure, including radiological procedures, on a patient. Correctly labeling specimens, radiographs, scans, etc., is also part of the patient identification process.
That said, mislabeling events are not uncommon despite the training and education provided to hospital staff and physicians. Every physician, especially those practicing emergency medicine, should be keenly aware of this issue, as they do not have any familiarity with the patients they are evaluating and are critically dependent upon accurate information from the diagnostic studies they order. Healthcare providers also must be aware of any polices or protocols that may cause or increase the risk of harm to patients. It is essential that hospital personnel review a patient’s radiology scans to confirm that the demographics of the patient are true and correct before beginning to interpret the images. Although these procedures take only a few moments, failure to adhere to them can lead to the events that occurred in this case.
Here, if the radiologist had compared the woman’s CT scan from 2007, which showed surgical clips from a removed gallbladder, with the new CT scan from 2009, which clearly contained a gallbladder, the radiologist would have known that the new CT scan was not that of the woman. Unfortunately, radiologic result discrepancies are not uncommon. Interpretation of results can have a degree of subjectivity that must be dealt with, especially if the results do not match the clinical picture, as in this case. Even if the radiologist did not compare the 2009 image with the 2007 image, there was an opportunity to repeat the scan or order additional studies, such as an ultrasound or MRI to confirm the result of the CT scan, especially since the patient was not presenting with critical symptoms.
It is equally important that healthcare personnel report any incidents in which problems arise with patient care and take the necessary steps to remedy existing polices and protocols or implement new standards to ensure no repeated incidents. Here, although the surgeon who performed the laparotomy reported to the radiology department that his surgical findings did not support or comport with the radiological interpretation of the mislabeled CT, the hospital appears to have failed to file an incident report or conduct an investigation into the discrepancy.
It is extremely unusual for a hospital not to investigate an event of this kind. Moreover, it is against regulations from CMS, which could lead to the loss of the hospital’s participation in the Medicare and Medicaid programs. This risk is one most hospitals would never take. Because incident reports and internal investigations are protected from discovery in many states under various evidence codes, it is possible that these did exist, but were not disclosed to outside counsel. It is important to provide all documents to counsel and allow counsel to determine what is relevant and what must be produced to the other side or presented in court.
This case also discusses the role of expert witnesses in determining the expected levels of skill and knowledge that apply to medical personnel. The woman retained multiple surgical experts who determined that the proper standard of care, according to national standards, required that the hospital take certain measures to ensure that the CT scans were not mislabeled. The experts also were critical in establishing that the cause of the woman’s prolonged chronic pain was due to complications that arose as a direct result of her unnecessary laparotomy. Therefore, it is important that healthcare providers are aware of the standard of care that applies to them under the law.
Court of Common Pleas of Delaware County, Pennsylvania, Case No. 2011-007715 (April 29, 2016).