The main reason patients sue is for an adverse event caused by delayed, missed, or failed diagnosis, says Jacqueline Ross, RN, PhD, coding director for patient safety and risk management with The Doctors Company, a malpractice insurer based in Napa, CA. Diagnostic errors can be multifactorial.

“In healthcare, providers rely on their cognitive skills when considering diagnoses, but they need to be aware of potential cognitive errors,” she explains. “One may be anchoring, which can be relying on the initial impression or diagnosis with conflicting information coming.”

Ross cites an example involving a patient who visited the emergency department (ED) on three separate occasions. The patient had a history of diabetes and chronic back pain. At the first visit, the patient presented with a fever and elevated white blood cells. After a lumbar puncture, the ED physician diagnosed viral meningitis.

A few days later, the patient returned with ongoing back pain, but with radiation to his abdomen. He also experienced spine tenderness. His white blood cell count had decreased, but his bands were elevated. His fever remained. The ED physician diagnosed ongoing chronic back pain, ordering muscle relaxers and pain medicine.

“Four days later, the patient returned with no feeling or ability to move his legs. Cauda equina syndrome was suspected, and a stat MRI showed a spinal epidural abscess [SEA] at T7-8 with cord compression,” she says. “The man now has incomplete paralysis of his legs and a neurogenic bladder. It was noted by multiple clinical experts that the ED physicians failed to note the various stages of the SEA, and if they had, the paralysis would have been avoided.”

The patient was in SEA Stage 1, but no one considered this diagnosis or ordered imaging.

“Another factor we picked up was the failure or delay in ordering diagnostic tests in postoperative patients. We completed a study, not yet released, about general surgeons and diagnostic errors and found that CTs were the most common tests delayed or not ordered postoperatively,” Ross explains. “There are also problems with misinterpretation of diagnostic tests that can lead to patients filing malpractice claims. Many of those specialties involve radiologists and pathologists.”

In a general surgery study, The Doctors Company included a case example of a general surgeon who reviewed a CT angiogram and noted no vascular injury, when an injury existed. The patient lost their leg because of the misread, Ross says. The clinical experts noted the general surgeon was not qualified to read the CT angiogram because of the lack of vascular training.

Failure to Communicate

Another reason patients sue is due to failure of communication, which led to an adverse event. Ross cites one example.

“A patient had laparoscopic surgery and had the abdomen collapse intraoperatively due to the insufflation device being out of gas,” Ross recalls. “The general surgeon exchanged tanks and, with the equipment in place, reinflated the abdomen and continued surgery. But there was no documentation of this event.”

In the post-anesthesia care unit, the patient had a firm, painful, distended abdomen. A CT of the abdomen with contrast was performed, but the operating room event was not communication to the radiologist.

The impression was a pneumoperitoneum, possibly due to recent surgery, Ross says. None of the nurses were aware of the equipment failure and the family was not told. Early in the morning, the patient developed severe abdominal pain, with a very distended abdomen and no bowel sounds. The surgeon was not called.

“A few hours later, the patient had a code and died. This case had multiple failures in communication and missed opportunities to hand off important information,” Ross says. “Had the information been shared, then the other healthcare providers could have been aware of potential problems.”


  • Jacqueline Ross, RN PhD, Coding Director, Patient Safety and Risk Management, The Doctors Company, Napa, CA. Phone: (800) 421-2368.