Malpractice Case Shows Risk from Physician Not Dating and Initialing Reports

Physicians must be certain that there is a process in place to ensure that no imaging, laboratory, or consultant’s report is ever filed unless it has been dated and initialed by the physician as proof that it was reviewed. Many medical liability claims would be prevented by this simple policy.

It is also important to create a suspense file or electronic health record (EHR) follow-up list for all ordered imaging studies, laboratory tests, diagnostic procedures, and consultations—to ensure that they were completed and that the physician reviewed the reports.

The following case is an example of a “perfect storm” that led to a malpractice claim:

A patient over the age of 50 was referred by the primary care physician to an orthopedist for evaluation of a two-year history of low back pain. The orthopedist ordered x-rays, which showed a questionable lytic lesion measuring 6 cm in diameter in the right iliac bone just superior to the acetabulum. The orthopedist’s routine was to personally review his patients’ x-rays, which he did in this case, but he focused on the lumbar spine and did not see the lytic lesion. The radiology report was sent to the orthopedist’s office and filed without his review. No office policy existed to ensure that reports were filed only after he had initialed and dated them.

An x-ray taken eight months later again showed the large lytic lesion in the pelvis. The orthopedist reviewed the films and again missed the lytic lesion. The radiology report was not found in the orthopedist’s file.

Four months later, the orthopedist performed an L5 laminectomy. Follow-up x-rays again noted the expansile lytic lesion. These films were reviewed by the orthopedist, who focused on the operative site in the lumbar spine and failed to see the lesion. The radiologist’s report was faxed to his office and filed; it had not been brought to his attention.

An MRI done one month later showed a lobulated, expansile lesion in the pelvis, suspicious for low-grade chondrosarcoma. The radiologist phoned the orthopedist to discuss the findings—it was the first time the orthopedist realized that an abnormality was present.

The patient was immediately referred to a major medical center, where the patient underwent partial resection of the pelvis and hip with amputation of the right leg. A claim was filed alleging failure to appreciate the presence and significance of a lesion diagnosed as chondrosarcoma more than three-and-a-half years after it was first noted in the filed radiology reports.

The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider in light of all circumstances prevailing in the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.


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