Case Study: Diagnosis Delay Results in Patient Expiration

Repurposed from The Scope, Medical Edition, Fourth Quarter 2023.

This case involved allegations of a delay in the diagnosis and treatment of a pulmonary embolism that resulted in the death of a 51-year-old male.

Initial Treatment

The patient was admitted to the emergency department on August 5, 2015, with complaints of chest pain and shortness of breath. His medical history was significant for morbid obesity, high cholesterol, cardiomyopathy, pericarditis, prior cardiac catheterization, diverticulitis and prior knee surgery.

A cardiac event was suspected, and the patient was given Plavix and underwent cardiac catheterization with the administration of Heparin. But, the catheterization failed to reveal the cause of the patient’s symptoms. Following the catheterization procedure, the patient’s pulse and lung sounds were normal. Despite this, a subsequent chest x-ray revealed mild cardiomegaly and vascular congestion. A D-dimer study was also elevated; a lower leg Doppler study was negative for deep vein thrombosis and an order for an echocardiogram was given.

The MLMIC-insured pulmonologist saw the patient the following day, and he was resting comfortably. Based upon the D-dimer results and the chest x-ray, he suspected a pulmonary embolism and ordered a CT angiogram. The CT angiogram was ordered at 3:35 p.m. However, the pulmonologist did not document his suspected diagnosis in the record, and the CT was not ordered on a STAT basis due to concerns that injecting dye could lead to kidney failure in a patient who recently underwent a cardiac catheterization. The pulmonologist also ordered Lovenox.

Patient Condition Worsens

Later that day, at 9 p.m., the patient developed shortness of breath, chest pain and was administered oxygen. The covering pulmonologist (also a MLMIC policyholder) was notified. He ordered a chest x-ray and advised the nurse to obtain arterial blood gases and contact the PA with the findings. The patient’s blood gas was slightly abnormal, and his oxygen saturation continued to drop. He was also tachycardic and experienced some chest pressure.

A PA saw the patient and administered Lasix due to the suspected congestive heart failure as seen on the chest x-ray. He also ordered a CT angiogram to be performed, STAT, which revealed extensive bilateral pulmonary emboli, with the echocardiogram revealing right heart strain. The CT angiogram was ordered the next day at 1:27 a.m. The radiologist transmitted the results around 1:57 a.m.

At 4 a.m., the PA administered Lovenox. The PA attempted to reach the covering pulmonologist, but did not hear back until 6 a.m. due to the insured’s phone being inadvertently turned off. When the covering pulmonologist was reached and advised of the patient’s condition, he informed staff that the other insured pulmonologist would be in shortly.

At 9 a.m. the following morning, the first pulmonologist saw the patient and based upon test results, including an elevated troponin level, was concerned the patient was going into heart failure. Even though the patient had received Lovenox six hours earlier, which would still be in his system, he felt the benefits of administering TPA outweighed the risk of an intracranial bleed.

TPA was discussed with the patient, including the risks, and the patient agreed to TPA administration. A few hours later, the patient became confused. A CT scan revealed he had suffered a large bleed in his brain. Surgery was unsuccessful in removing the bleed or alleviating the swelling, and the patient expired the following day.

Lawsuit and Settlement

A lawsuit was filed, with the allegations centered around the negligent administration of anticoagulant and TPA, resulting in intracranial hemorrhage, craniotomy and the death of the patient. The plaintiff’s focus was on the elevated D-dimer and troponin results from the initial examination and an alleged delay in the diagnosis and treatment of pulmonary embolism.

Both pulmonologists failed to meet the standard of care. The first pulmonologist should have ordered a CT angiogram STAT and made sure the patient was receiving sufficient heparin. There was an approximately 48-hour delay in the diagnosis and treatment of the pulmonary embolus. There was also a delay in returning phone calls by the overnight on-call pulmonologist. There were no alternative diagnoses to better explain the patient’s shortness of breath and tachycardia. That, along with a positive D-dimer, should have led to a high likelihood of pulmonary embolism and the start of full-dose anticoagulation.

The plaintiff’s demand was $6.5 million, and the case settled on behalf of both insured pulmonologists within their policy limits.

A Legal and Risk Management Analysis

Delayed diagnosis is a common claim in medical malpractice cases and is attributed to both human and system-level factors. The plaintiff’s focus in this case was on human error attributed to the pulmonologists — inadequate assessment, documentation error, untimely on-call response and failure to appear and perform a patient evaluation in person. From a risk management focus, it is important for the organization to look beyond the plaintiff’s claim. The organization must perform a deeper dive to determine whether organizational or system factors contributed to the human error. These factors include time-related pressures or situational and environmental factors such as time of day, overcrowding and workforce/staffing shortages.

MLMIC policyholders can reach out to our legal department for questions regarding system-level factors that contribute to claims or to inquire about any other healthcare law issues by calling (877) 426-9555 Monday-Friday, 8 a.m.-6 p.m. or by email here.

Our 24/7 hotline is also available for urgent matters after hours at (877) 426-9555 or by emailing hotline@tmglawny.com.

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This document is for general purposes only and should not be construed as medical or legal advice. This document is not comprehensive and does not cover all possible factual circumstances. Because the facts applicable to your situation may vary, or the laws applicable in your jurisdiction may differ, please contact your attorney or other professional advisors for any questions related to legal, medical or professional obligations, the applicable state or federal laws or other professional questions.