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Surgeon Assumes Supplemental Report is Copy of Prior Report
ISSUE: What is a physician's duty to ensure that every laboratory or consultant's report is reviewed?
A 46-year-old recent immigrant went to the emergency department of a large university hospital with complaints of chest pain and a "racing heart." An echocardiogram demonstrated that the patient had a bicuspid aortic valve with moderate to severe aortic stenosis and moderate aortic regurgitation. He was scheduled to undergo surgical repair.
A cardiovascular surgeon performed the scheduled surgery that included an aortic root replacement with implantation of an artificial valve, hemi-arch replacement, an epicardial maze procedure, and ligation of the left atrial appendage. Specimens removed during the procedure were sent for pathological analysis. The pathology studies of the aortic root valve were reported two days later. The native aortic valve tissue had signs of acute and healing endocarditis but no organisms were identified.
The patient was discharged five days later with instructions to follow up with a cardiologist and with the surgeon in six weeks. An addendum to the pathology report, dated two days after the patient was discharged and that was similar in appearance to the original report although with a more recent date and marked "amended report" indicated that the aortic valve specimen had "an additional focus of degeneration of the valve with necrosis of fibrous tissue, fibrinous exudates, infiltrates of neutrophils, and also healing with granulation tissue." A copy of the report was sent to the surgeon's office, but as he had not submitted any additional specimens he glanced at it, assumed it was a duplicate of the original report and did not review it further.
One week after discharge, the patient was seen by a cardiologist. At that time, the patient complained of a slight cough and chest wall discomfort.
Two weeks later, the patient returned to the hospital by ambulance with a fever of 102.1° and complaints of chills and shortness of breath. Blood work revealed an elevated white blood cell count and blood cultures indicated Gram-positive cocci, Streptococcus mitis and Streptococcus salivarius. He was started on a course of antibiotics, but became unresponsive early the next morning. He was transferred to the intensive care unit and intubated. The following day a transesophageal echocardiogram (TEE) showed vegetation on the prosthetic aortic valve. One day later, magnetic resonance imaging revealed that the patient had a massive stroke thought to have resulted from septic emboli. He went into a coma and died one month later.
The family sued the surgeon, alleging that he departed from the standard of care by failing to timely diagnose and treat the patient's endocarditis. They contended that the surgeon failed to review the supplemental pathology report and appreciate the presence of endocarditis in that report; failed to prescribe the appropriate antibiotics to treat the endocarditis; and allowed the endocarditis to progress.
The surgeon admitted that he had not reviewed the supplemental report but argued that it would not have changed his management and that the infection was unrelated to any previous endocarditis.
A 46-year-old recent immigrant went to the emergency department of a large university hospital with complaints of chest pain and a "racing heart." An echocardiogram demonstrated that the patient had a bicuspid aortic valve with moderate to severe aortic stenosis and moderate aortic regurgitation. He was scheduled to undergo surgical repair.
A cardiovascular surgeon performed the scheduled surgery that included an aortic root replacement with implantation of an artificial valve, hemi-arch replacement, an epicardial maze procedure, and ligation of the left atrial appendage. Specimens removed during the procedure were sent for pathological analysis. The pathology studies of the aortic root valve were reported two days later. The native aortic valve tissue had signs of acute and healing endocarditis but no organisms were identified.
The patient was discharged five days later with instructions to follow up with a cardiologist and with the surgeon in six weeks. An addendum to the pathology report, dated two days after the patient was discharged and that was similar in appearance to the original report although with a more recent date and marked "amended report" indicated that the aortic valve specimen had "an additional focus of degeneration of the valve with necrosis of fibrous tissue, fibrinous exudates, infiltrates of neutrophils, and also healing with granulation tissue." A copy of the report was sent to the surgeon's office, but as he had not submitted any additional specimens he glanced at it, assumed it was a duplicate of the original report and did not review it further.
One week after discharge, the patient was seen by a cardiologist. At that time, the patient complained of a slight cough and chest wall discomfort.
Two weeks later, the patient returned to the hospital by ambulance with a fever of 102.1° and complaints of chills and shortness of breath. Blood work revealed an elevated white blood cell count and blood cultures indicated Gram-positive cocci, Streptococcus mitis and Streptococcus salivarius. He was started on a course of antibiotics, but became unresponsive early the next morning. He was transferred to the intensive care unit and intubated. The following day a transesophageal echocardiogram (TEE) showed vegetation on the prosthetic aortic valve. One day later, magnetic resonance imaging revealed that the patient had a massive stroke thought to have resulted from septic emboli. He went into a coma and died one month later.
The family sued the surgeon, alleging that he departed from the standard of care by failing to timely diagnose and treat the patient's endocarditis. They contended that the surgeon failed to review the supplemental pathology report and appreciate the presence of endocarditis in that report; failed to prescribe the appropriate antibiotics to treat the endocarditis; and allowed the endocarditis to progress.
The surgeon admitted that he had not reviewed the supplemental report but argued that it would not have changed his management and that the infection was unrelated to any previous endocarditis.
From your analysis of the case, assess whether the following statesments are true or false:
| * | Every newly received report regarding a patient must be carefully reviewed. | True or False |
| * | A physician may assume that a laboratory or consultant amending a prior report will mark such changes in bold letters clearly indicating a change in the information. | True or False |
| * | A busy surgeon can delegate to a secretary or receptionist the task of sorting laboratory and consultant reports into those needing review and those that can be filed. | True or False |
Expand to check answers
GENERAL PRINCIPLE: Even if a newly received document appears to be simply a duplicate of a previously received result, careful review is necessary to ensure it is not a different, amended or supplemented report.
APPLIED PRINCIPLE: Laboratories and consultants may send multiple copies of reports to hospitals, treating physicians and on occasion to the patient, but a physician receiving what appears to be a duplicate copy of a previously reviewed result must read the new report in detail. The laboratory or consultant may send a new or supplemental report or may send the original document with an addendum. Such additional information may contradict a prior report or add critical new information, and failure to review it may cause patient injury.
The original pathology report indicated possible evidence of prior infection, but no organisms were seen and the surgeon believed that no antibiotic coverage was necessary. The supplemental report describing exudates and neutrophil infiltration may have more strongly suggested current infection and prompted patient recall and/or infectious disease consultation.
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APPLIED PRINCIPLE: Laboratories and consultants may send multiple copies of reports to hospitals, treating physicians and on occasion to the patient, but a physician receiving what appears to be a duplicate copy of a previously reviewed result must read the new report in detail. The laboratory or consultant may send a new or supplemental report or may send the original document with an addendum. Such additional information may contradict a prior report or add critical new information, and failure to review it may cause patient injury.
The original pathology report indicated possible evidence of prior infection, but no organisms were seen and the surgeon believed that no antibiotic coverage was necessary. The supplemental report describing exudates and neutrophil infiltration may have more strongly suggested current infection and prompted patient recall and/or infectious disease consultation.
| * | Every newly received report regarding a patient must be carefully reviewed. | True |
| * | A physician may assume that a laboratory or consultant amending a prior report will mark such changes in bold letters clearly indicating a change in the information. | False |
| * | A busy surgeon can delegate to a secretary or receptionist the task of sorting laboratory and consultant reports into those needing review and those that can be filed. | False |