Some malpractice lawsuits allege significant incidental findings discovered after discharge were never communicated to patients.
“With more and more imaging being done, it’s become more prevalent. It’s a huge patient safety issue,” says Alan Lembitz, MD, chief medical officer at COPIC, a Denver-based medical professional liability insurance provider.
Many EDs have created fine-tuned processes to keep this from happening. “We don’t miss many of those because we’ve been harping on our EPs so much to say, ‘This is the only chance this person will ever get to find out they’ve got an incidental nodule or lesion that needs further workup or surveillance,’” Lembitz explains.
COPIC instructs its ED clients to give patients the imaging disk when possible. At a minimum, patients should receive the results and instructions on how and why to follow up. “Our ED doctors are getting that message and are doing very well,” Lembitz reports.
Education on structured handoffs and closed loop communication “is bearing fruit for people discharged from the ED,” Lembitz notes.
However, malpractice claims are occurring with admitted patients. The fact patterns all are similar: Tests are ordered while the patient remains in the ED. Results come back after the patient is upstairs — and no one ever follows up.
One such lawsuit involved a patient whose CT scan showed acute appendicitis and a renal lesion. The patient underwent a successful appendectomy, went home, and attended a postoperative follow-up visit with the surgeon — and never heard anything about the renal lesion.
A year and a half later, the patient was diagnosed with advanced renal cell carcinoma. “The assumption is: I admit you for sepsis, appendicitis, or another acute condition, and the subsequent accepting surgical or hospital service is going to look back on all the tests in the ED that I did. And they don’t,” Lembitz observes.
The patient is physically upstairs and out of the ED. The EP believes the admitting physician is going to see the incidental findings and inform the patient at some point before discharge. In reality, only the findings pertinent to the hospitalization are discussed.
“Surgical services manage the surgical problem. They don’t always look back and see an incidental finding from a test ordered in the ED,” Lembitz notes.
COPIC has seen multiple recent cases of missed cancer where neither the hospitalist nor the surgical service caught significant incidental findings from tests ordered in EDs. “In the heat of being admitted for their primary diagnosis, these other things just don’t come up,” Lembitz shares.
EPs do not handle discharge summaries with patients who are admitted. “That step is omitted. We are trusting somebody down the line,” Lembitz says.
The assumption is that if something is in the EMR, it is going to be seen by other providers. In reality, the worrisome finding is lost in the voluminous record. “When you talk to hospitalists or services, they’re totally frustrated. They say they can’t go back and review everything that was done in the ED,” Lembitz reports.
If nobody ever informs the patient of the abnormal finding, both the EP and the admitting physician are likely to be named in malpractice litigation. “The EP takes part of the hit because the EP’s name is on the study that was done in the ED,” Lembitz says.
It is not enough to caution EPs to “just be more careful.” EHRs can flag abnormal findings appropriately without creating “alarm fatigue.” Reviewing cases where things went wrong, without blaming individual ED providers, can raise awareness.
“This can lead to a cultural shift among providers, that abnormal results need to be brought to the patient’s attention whenever anyone sees them,” Lembitz offers.
Daniel LaLonde, MD, says if these test results return after the patient makes it to an inpatient bed, legal problems could emerge:
• The band count included in a differential of a complete blood count is missed because it comes back after other results. This tends to lag behind the reporting of the white blood cell count and hemoglobin levels. “But it can contain some very important information,” LaLonde notes. “Increased bands are a marker of sepsis and can be easily missed.”
• Imaging study results are missed because the ED patient goes straight to their inpatient bed from radiology. “It is the responsibility of the ordering physician to follow up on these results,” says LaLonde, associate medical director of the ED at Ascension Providence in Southfield, MI.
The EP must communicate to the admitting team that the study is pending, and that the admitting team is responsible for following up on the results. “The admitting physician most certainly assumes care of that patient when they are transferred to the floor,” LaLonde says. “But good closed-loop communication leads to better patient care.”
Once the patient leaves the ED and the admitting physician assumes care, the responsibility lies with the admitting physician. “At that point, it is on that physician to use all of the testing and information that was garnered in the ED, and report to the patient any of the incidental findings,” LaLonde explains.
• Patients are discharged from the ED after a chest X-ray or CT scan without finding out they have a pulmonary nodule. LaLonde typically documents these conversations in the patient’s chart, includes the information in discharge paperwork, and recommends to patients they see their primary care physician.
“The danger of not counseling the patient in these situations is that the nodule turns out to be malignant, and the patient goes without proper follow-up,” LaLonde says.