Legal Review & Commentary: Woman alleges negligence: $4.3 million settlement
Legal Review & Commentary
Woman alleges negligence: $4.3 million settlement
By Radha V. Bachman, Esq. Lynn Rosenblatt, CRRN, LHRM
Buchanan Ingersoll & Rooney PC HealthSouth Sea Pines Rehabilitation Hospital
Tampa, FL Melbourne, FL
News: A woman presented at a hospital emergency department (ED) with abdominal pain. X-rays and a CT scan were performed. The emergency physician discussed the findings with a radiologist who noted the findings in his report. The emergency physician noted the CT as negative and ordered the woman to take morphine and fentanyl. Twelve hours later, the woman was seen by a different physician, who reviewed the previous record but did not mention the X-rays or the CT scan. The woman was given oxycodone and released with a prescription for Percocet. The next day, the woman saw her family physician, who scheduled her for an appointment with a vascular surgeon. The vascular surgeon advised that the woman see a hematologist within two months. The woman never saw the hematologist and, eventually, suffered from intestinal death, requiring intravenous feedings. A settlement was reached in the amount of $4.3 million.
Background: A 37-year-old woman arrived at the ED of a hospital with complaints of severe abdominal pain. The ED physician ordered a CT scan and abdominal X-rays. The scan reportedly detected a "spleen with heterogeneous perfusion (possible infarct)" and a "filing defect in abdominal aorta." The ED physician discussed the results with a radiologist, who included this information in his report and also noted that the filing defect may "represent local thrombus formation and may be a source of distal emboli." Prior to sending the woman home, the ED physician diagnosed the abdominal pain as arising from an unknown cause and determined that the CT scan was negative. The ED physician prescribed morphine and fentanyl and told the woman to return to the hospital 12 hours later.
When the woman returned to the hospital, she was seen by a different physician, who noted in her chart that he had reviewed the record but did not mention or explain the radiologist's findings. The physician prescribed oxycodone with a script for Percocet and an order to see her family physician the following day. During her visit with the family physician, the woman was told that she needed to see a vascular surgeon. The surgeon immediately scheduled a chest CT, echocardiogram, and blood clotting disorder study. An appointment was made for the woman to see a hematologist two months later. Due to transportation issues, the woman was unable to make her appointment. Less than one month later, the woman's abdominal aortic thrombus extended and blocked arterial blood flow to her intestines, resulting in intestinal death and requiring removal of all but 20 cm. of her intestines.
The woman sued the hospital and various physicians, alleging that she never was fully informed regarding the necessity of the hematology tests and that the defendants were negligent in allowing her condition to exacerbate to the point of complete loss of her intestines. The defendants denied negligence but did not proffer any alternate causes of the intestinal death. A $4.3 million settlement was reached between the parties.
What this means to you: The major departure from a recognized standard of care most likely occurred in this case at the point when the first ED physician sent the patient home with a determination that the CT scan was negative. It can be assumed that there were substantial findings, and that the radiologist actually detected a medical issue that did indeed become the etiology of the patient's loss of her intestines.
Since the radiologist and the first ED physician did speak and one can only assume that the radiologist did discuss the positive findings of a possible splenic infarct and a filling defect in the abdominal aorta that represented the possibility of local thrombus formation and a source of distal emboli, the ED physician was negligent in not addressing these possibilities prior to discharging the patient.
The medications that were prescribed, morphine and fentanyl, are potent analgesics, which would call into question why he would release a patient who required such an intense level of pain control without first determining the source of the pain or at least continuing to observe the patient to assure that nothing further developed. His failure to properly diagnose is evident from the lack of attention that was paid to the radiology findings.
An ED is a frantic, volatile, and hostile environment that, by its very nature, is ripe for medical misadventure. Patients come and go over a 24-hour period. It is possible for a single patient to be seen by scores of staff and physicians of various specialties. It is equally likely that none of them has ever seen the patient before or will care for that patient again. The ED staff collectively see many patients at the same time. Emergent cases get priority over urgent ones. It is relatively easy to imagine how this woman could have been "lost," as that is exactly what happened.
The fact that two physicians did not note or mention the radiology report would indicate that it either was not in the chart or the chart was not reviewed in its totality. To assure quality and safety, it is imperative that hospitals have safeguard systems that ensure that the care provided is timely, accurate, and based on reasonable diagnostic testing appropriate to the patient's presentation. This patient again was discharged without any indication that the seriousness of her condition was recognized and properly dealt with.
Just as the first ED physician passed her on to a second, the second passed her off to her community-based physician. This physician obviously was not aware of the existing CT scan, nor did he or her family physician take an accurate history from the patient. If they had, they would have known that her original complaint was abdominal in nature and that she had a CT scan in the ED two days previous.
In most communities, private practice physicians have near-instantaneous access to a patient's hospital record upon the authorization of the patient. In this case, if an accurate history had been obtained, both the family physician and the surgeon should have queried the hospital and obtained the ED records. Of course, that result would be dependent on the record actually containing her information and on the physicians appropriately requesting it.
In most health care settings, the information provided to the patient as to his or her condition and instructions for further care and the responsible use of prescribed medications is the responsibility of the provider. Patients treated in the ED are traditionally provided with an extensive synopsis of what has been done and recommendations for further testing and follow-up appointments. The patient must be instructed on the importance of information provided and the need to share those documents with referral sources to ensure continuity of care. This constitutes "patient handoff." Both patient education and handoff are significant standards in hospital accreditation processes and are recognized as one of the National Patient Safety Goals, which is amended yearly by The Joint Commission.
It is clear from the narrative and the horrific results that none of the providers paid due diligence to their respective obligations to this patient. The ED physicians saw her but did not truly treat her symptoms in an appropriate manner and passed her on to her family physician, who referred her to yet another specialist, who apparently did not solicit sufficient information to substantiate his tentative diagnosis. Time was wasted by testing that may not have been appropriate to the actual presentation, which now was lost to the ever-increasing chain of providers.
If this patient had been admitted at the time of the first ED visit, when a radiologist identified positive findings with serious consequences, this could have been avoided. A settlement of $4.3 million seems reasonable for a 37-year-old patient who has been subjected to a seriously diminished quality of life with a greatly shortened life expectancy.
Reference
Anonymous. Case No. unknown.
News: A woman presented at a hospital emergency department (ED) with abdominal pain. X-rays and a CT scan were performed. The emergency physician discussed the findings with a radiologist who noted the findings in his report. The emergency physician noted the CT as negative and ordered the woman to take morphine and fentanyl. Twelve hours later, the woman was seen by a different physician, who reviewed the previous record but did not mention the X-rays or the CT scan.Subscribe Now for Access
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