Legal Community & Review-Failure to read MRI leads to $410,000 settlement

News: The failure to appropriately read an MRI done in the emergency room resulted in the misdiagnosis of a herniated disc. The plaintiff became paralyzed, and the case against the physicians resulted in a $410,000 settlement.

Background: On a Saturday morning, a 44-year-old man experienced acute lower back pain and weakness in his legs while attempting a bowel movement. The pain was severe enough that he was taken from his home to the emergency room by ambulance. The emergency room physician ordered a lumbar MRI, which she apparently believed to be negative. She shared the results with the plaintiff and his family. She claimed that the radiologist told her the results, but she did not indicate his interpretation in the plaintiff's medical record.

Deterioration in patient's condition

The radiologist on call that day denied having interpreted the MRI on the day the plaintiff was seen in the emergency room, and there was no indication in the medical record that he had read the MRI. While the patient was in the emergency room, his condition worsened to the point where he lost some ability to flex his feet. At that point, the emergency room physician called in a neurologist.

The neurologist admitted the patient to the hospital. By that evening, the patient was not able to walk or urinate. However, the neurologist did not see the patient until the following morning, at which time he performed a lumbar puncture and diagnosed Guillian-Barre syndrome, an ascending transient paralysis. The neurologist diagnosed Guillian-Barre partly because the paralysis started with the patient's feet and seemed to travel up his legs, a telltale sign of the disease. After discharge, the plaintiff spent weeks in rehab and physical therapy, but his condition did not improve, and the paralysis did not travel back down his legs, as would be expected with Guillian-Barre.

At that point, he sought a second opinion and was seen by another neurologist, who repeated the MRI and found the herniated disc. Despite surgery to repair the disc, the plaintiff remains paralyzed with a neurogenic bladder for which he must catheterize himself, and he has no sensation during sexual intercourse. The case was settled against the first neurologist and the emergency room physician for $410,000.

What this means to you: This case includes the classic risk management nemesis, failure to properly document, says Mary O'Mara, RN, MPA, vice president for risk management at Saint Joseph's Medical Center in Yonkers, NY. Proper documentation of the alleged interaction between the radiologist and the emergency physician may have made a difference when the emergency physician was held responsible for her judgment call, she says.

"We manage emergency department physician contacts directly on the patient's medical record. There is a special section for the ED physician to document the time he or she calls the patient's physician or a consultant, and the time the call is returned," she says. "Recom mend ations made are documented in the progress note section of the medical record by the ED physician. In the case in question, it appears that such a system was not in place or not properly used."

Documentation overhaul needed

O'Mara also questions what efforts the hospital staff took to notify the neurologist or the patient's attending physician when it was noted that the patient's condition was rapidly deteriorating shortly after admission to the hospital.

In such a situation, nursing staff or a nursing supervisor should call the neurologist to alert him or her of the dramatic changes, she says. If there were no response or an inadequate response, the issue should be pursued with the director of medical service, she says, and even further with the medical director of the hospital. Of course, all of those steps must be documented to be worthwhile, O'Mara says.

Some systematic changes in documentation and improved lines of communication could have helped to avoid this outcome, she suggests.

"Good documentation in the medical record assists in providing a continuum of care for the patient," O'Mara says. "If both good documentation and communication had been a part of this patient's care, I believe the outcome could have been quite different."

Reference

Steven Weinstein v. Mark C. Schultz, MD, and Cheryl Cochrane, MD, San Fernando County (CA) Superior Court, Case No. PC 018229 Z.