Legal Review & Commentary

Delayed diagnosis of aortic dissection results in $4.5M award for wrongful death

News: A 43-year-old man presented to the emergency department with complaints of chest pain. A CT scan of the chest without contrast showed evidence of a possible dilated ascending aorta. The patient was admitted to the hospital for further observation and testing. Multiple tests were ordered, but the orders never were entered into the hospital system and, therefore, were not performed. An echocardiogram was finally performed and indicated that the patient had an aortic dissection. Before a surgeon could be located, the patient died from complications of the ascending aortic dissection. The patient’s family filed suit against the hospital and multiple doctors, and the case advanced to a jury trial. The jury awarded the patient’s family $4.5 million.

Background: A 43-year-old man, with no history of cardiac issues and a history of smoking, presented to the emergency department with complaints of chest pain. At approximately 6:55 a.m., a CT scan of the chest without contrast showed evidence of a possible dilated ascending aorta. The radiologist informed the emergency department physician of the results and recommended that a CT angiogram of the chest be ordered to rule out certain conditions. The emergency department physician, in turn, ordered that a CT angiogram be performed once the patient was admitted to the hospital floor but did not otherwise order that it be performed while he remained in the emergency department. The patient was admitted to the hospital between 7 a.m. and 8 a.m. However, the CT angiogram ordered by the emergency department physician was never entered into the hospital system and, thus, was never performed. The patient was examined by the cardiologist between 10:30 a.m. and 11 a.m., and a CT scan of the chest with contrast was ordered. Again, the order never was entered into the hospital system and, again, never was performed. Thereafter, between 12:30 p.m. and 1:30 p.m., the cardiologist ordered an echocardiogram that was performed and indicated that the patient had an aortic dissection. At approximately 4:12 p.m., before a surgeon could be located, the patient died from complications of the ascending aortic dissection.

A lawsuit was filed against the hospital, emergency department physician, internal medicine attending, cardiologist and the cardiology group, by the patient’s mother. Plaintiff alleged that defendants failed to timely order and perform the CT scan of the chest with contrast and CT angiogram of the chest, and the plaintiff alleged that the defendants failed to timely diagnose and treat the decedent’s aortic dissection. Specifically, plaintiff claimed that the emergency department physician was negligent in failing to order and obtain the CT scan with contrast in a timely manner and thus, failed to timely diagnose the aortic dissection. Furthermore, plaintiff claimed the internal medicine attending was negligent in failing to ensure that the CT scan of the chest with contrast was performed when the decedent was admitted and failed to ensure the decedent was examined by a cardiologist in a timely manner. Plaintiff further claimed that the cardiologist and cardiology group were negligent in failing to timely examine the decedent and order and follow up the results of the tests necessary to diagnose the aortic dissection.

The case proceeded to a jury trial. The emergency department physician, cardiologist, cardiology group, and internal medicine attending denied all allegations of negligence in the matter. The hospital was the only party to admit to the allegations of negligence. The jury determined that the internal medicine attending and the hospital were negligent and proximately caused the decedent’s death. The jury’s $4.5 million award included $500,000 for pain and suffering, with the remainder allocated to the decedent’s four children in pecuniary loss. The attorneys for the hospital and the internal medicine attending reached a high/low agreement with the plaintiff wherein they would pay $3.5 million of the verdict. The hospital was responsible for $2 million. The high/low agreement reportedly was reached with other defendants who were not found negligent but were still required to contribute to the verdict.

What this means to you: The failure to diagnose a “triple A” in young, otherwise healthy individuals has received a lot of coverage in literature recently. In the typical case, the investigation reveals that the physicians don’t consider the diagnosis in the absence of alarm or traditional symptoms. Sadly in this case, it appears that the diagnosis might have been considered, yet the failure of the simple ministerial acts of getting the appropriate testing done and communicated contributed to the outcome.

We don’t have a medical record to review, but the ordering of a CT scan by the emergency department physician seems to indicate that the doctor was considering something more complex than angina, pneumonia, or the other more common causes of chest pain. So where did it go wrong? The radiologist conveyed the results of the CT scan with contrast showing the possibility of a dilated aorta, which had the potential to be a significant threat to the patient’s life or health. It appears from the recitation of facts that the radiology department complied with their standard of care by conveying the information to the emergency department attending physician and recommended a follow-up test. The emergency department physician ordered the test to be done after admission. This sequence of events highlights a common “falls-through-the-cracks” scenario common in hospitals. The period between the point in time when an emergency department physician decides to admit, and the point at which the admitting resident or attending takes over the care, is when we in the hospital need to be especially vigilant. If the emergency department physician on the basis of the CT scan thought the second test was necessary, should he/she not have ordered it immediately rather than waiting for admission?

The second order was not entered into the system; this is the advantage and disadvantage of electronic ordering. In the old “paper system,” a provider would write an order and place it in a location for retrieval by radiology or other support service. The advent of computerized ordering has streamlined this system and eliminated the “missing paper order” problem, but it creates issues of its own. The order has to be put into the system, which also sometimes requires that one clinical system communicate with another system, i.e. the clinical system has to trigger a notification in the radiology computer system. Hospital clinical staff and IT staff should be running quality assessment programs to ensure that everything that should be done is done and is accurately communicated. In this case, eventually an echocardiogram revealed the presence of an aortic aneurysm, but it was too late to save the patient.

So what do we take away from this case that might help our institutions avoid having a similar event? Ensure that physicians in the emergency department and other locations follow through. The emergency department doctor had a suspicion, which ultimately was right, but he/she may have failed to close the loop. Providers who put orders into electronic systems need to cycle back and make sure the orders have indeed been entered and are being done. From a clinical perspective, an assessment should be done to analyze whether the most efficacious test was done timely. In this case, the simple ultrasound eventually diagnosed the condition, albeit late. If there were a clinical suspicion of an AAA, would a fast exam in the emergency department have led to a quicker diagnosis and a better chance at saving the patient? The hospital in this case reportedly conceded liability and, we hope, was able to identify the root causes to prevent the same scenario from happening again.

Reference

2012 WL 5990342, No. 08-L-827 (Ill.Cir. Ct.).