Page 39 - 2022 Risk Basics - Radiology

SVMIC Risk Basics: Radiology

C A S E S T U DY

A 21-year-old female nonsmoker with a history of pregnancy-

induced hypertension, approximately six months post-partum,
presented to her PCP on April 18 with a productive cough (worse at

bedtime), chest tightness, and shortness of breath with ambulation
x3 weeks. Blood pressure was 100/80, pulse was 108, and lungs

were clear. She was diagnosed with bronchitis and prescribed
antibiotics and cough medicine. On April 23, the patient presented to

the emergency department with similar complaints except she was
now coughing up blood. On examination, lungs were auscultated

with rales noted in the left lung. A CXR and CBC were ordered
by the emergency department physician. The radiologist, who was

located at a different facility across the state line, reviewed the
CXR and dictated, “biventricular cardiac enlargement consistent

with cardiomyopathy” .

The radiologist immediately telephoned the ED and spoke to a

nurse who wrote the results on the demographic sheet next to the
order for the CXR. A copy of the radiology report was received in

the ED within 30 minutes. However, the emergency physician, who
was going off shift, did not review the results, despite signing both

the CXR order and the demographic sheet (it is unknown at what
time he signed the sheet or the nurse wrote the report, as there

was a shift change). The patient was discharged after the call and
the report was received with a diagnosis of “persistent bronchitis”.

The patient died four days later from congestive heart failure. The
emergency physician, the hospital, and the radiologist were all

sued. Ultimately, the radiologist was dismissed from the suit and a
large settlement was paid on behalf of the remaining defendants.

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