Jeffrey L. Susman, MD

Missed dissecting aortic aneurysm proves fatal

A 43-YEAR-OLD MAN was admitted to the hospital complaining of severe chest pain, shortness of breath, sweating, and dry mouth. After being seen by several physicians, the patient suffered an aortic dissection, which caused bleeding in the wall of the aorta, an aortic rupture, and bleeding into the pericardium. He died 2 days later.

PLAINTIFF’S CLAIM The defendants failed to order tests to rule out a dissecting aortic aneurysm and did not include aortic dissection in the differential diagnosis. They failed to provide appropriate drug therapy to decrease cardiac impulse and lower the systolic blood pressure. They did not obtain an emergency cardiac consultation or admit the patient to a cardiovascular surgical intensive care unit.

THE DEFENSE The defendants denied negligence and claimed that nothing they did or failed to do contributed to the patient’s death.

VERDICT $250,000 Michigan settlement.

COMMENT Just yesterday, a malpractice lawyer presented me with a case very similar to this one: a patient with unexplained chest pain who died of a dissecting aneurysm. Remember, not all chest pain is caused by coronary artery disease.

Too-late cancer Dx blamed on neglected x-ray findings

A LONG-TERM CIGARETTE SMOKER IN HER 50s saw a physician in 2001 for symptoms of pneumonia. The doctor prescribed antibiotics and referred her to another facility for a chest radiograph.

Five days later, she returned to the physician’s office, where she was seen by another internist in the practice. The internist noted that the chest radiograph showed parenchymal densities in the right lung. Parenchymal densities had also showed up on 2 previous chest radiographs, but were more prevalent on the latest film. The internist advised the patient to finish her antibiotic regimen; he did not prescribe further tests or treatment.

Over the following 40 months, doctors in the patient’s medical group examined her 8 times. Each time she complained of impaired respiration. The internist believed that the symptoms were caused by asthma.

In 2004, the patient was diagnosed with stage IV cancer of the right lung, which had spread to her bones and was untreatable. She died several weeks later.

PLAINTIFF’S CLAIM A proper diagnosis in 2001 would have allowed the cancer to be cured. A computed tomography scan should have been performed and a pulmonologist consulted at that time.

THE DEFENSE Findings from the radiograph from 2001 did not necessitate further action. Because the patient’s cancer had metastasized before that radiograph, treatment then (or later) would not have changed the outcome.

VERDICT $850,000 New York verdict.

COMMENT Careful follow-up and diagnosis of chest radiograph abnormalities is paramount.

Yes, it was a stroke

WEAKNESS, NUMBNESS, AND TINGLING IN HIS RIGHT ARM prompted a 56-year-old man to visit his primary care physician. The physician sent the patient to the emergency department (ED) for testing because he believed the man was experiencing stroke-like symptoms. As the patient and his wife drove to the hospital, the physician faxed the patient’s medical records to the ED.

When the patient’s wife tried to give ED employees the physician’s orders for tests and tell them of the doctor’s concern about a stroke, they told her that all the beds were full and she should sit down and wait.

The patient was eventually evaluated as a low-priority patient with numbness in his right hand. The examining doctor ordered radiographs of the right wrist and discharged the patient with a diagnosis of carpal tunnel syndrome.

Twenty minutes later, a nurse left a message telling the patient to return to the hospital for the stroke-related tests that had been ordered by his primary care physician. An ED physician other than the one who first examined the patient performed the tests—except for a test of blood flow to the brain. The physician diagnosed stroke-like symptoms and requested a consultation with another physician, which never happened. The patient was discharged about 6 hours after his first discharge.

About 16 hours later, the patient suffered a stroke. Subsequent testing revealed an obstruction in the left carotid artery. The stroke resulted in permanent neurologic injury.

PLAINTIFF’S CLAIM No information about the plaintiff’s claim is available.

THE DEFENSE The defendants denied negligence and disputed the extent of the patient’s injuries.

VERDICT $1.123 million Maryland verdict.

COMMENT Coordination of care remains critical, particularly between our outpatient offices and the busy ED.

Missed dissecting aortic aneurysm proves fatal

A 43-YEAR-OLD MAN was admitted to the hospital complaining of severe chest pain, shortness of breath, sweating, and dry mouth. After being seen by several physicians, the patient suffered an aortic dissection, which caused bleeding in the wall of the aorta, an aortic rupture, and bleeding into the pericardium. He died 2 days later.

PLAINTIFF’S CLAIM The defendants failed to order tests to rule out a dissecting aortic aneurysm and did not include aortic dissection in the differential diagnosis. They failed to provide appropriate drug therapy to decrease cardiac impulse and lower the systolic blood pressure. They did not obtain an emergency cardiac consultation or admit the patient to a cardiovascular surgical intensive care unit.

THE DEFENSE The defendants denied negligence and claimed that nothing they did or failed to do contributed to the patient’s death.

VERDICT $250,000 Michigan settlement.

COMMENT Just yesterday, a malpractice lawyer presented me with a case very similar to this one: a patient with unexplained chest pain who died of a dissecting aneurysm. Remember, not all chest pain is caused by coronary artery disease.

Too-late cancer Dx blamed on neglected x-ray findings

A LONG-TERM CIGARETTE SMOKER IN HER 50s saw a physician in 2001 for symptoms of pneumonia. The doctor prescribed antibiotics and referred her to another facility for a chest radiograph.

Five days later, she returned to the physician’s office, where she was seen by another internist in the practice. The internist noted that the chest radiograph showed parenchymal densities in the right lung. Parenchymal densities had also showed up on 2 previous chest radiographs, but were more prevalent on the latest film. The internist advised the patient to finish her antibiotic regimen; he did not prescribe further tests or treatment.

Over the following 40 months, doctors in the patient’s medical group examined her 8 times. Each time she complained of impaired respiration. The internist believed that the symptoms were caused by asthma.

In 2004, the patient was diagnosed with stage IV cancer of the right lung, which had spread to her bones and was untreatable. She died several weeks later.

PLAINTIFF’S CLAIM A proper diagnosis in 2001 would have allowed the cancer to be cured. A computed tomography scan should have been performed and a pulmonologist consulted at that time.

THE DEFENSE Findings from the radiograph from 2001 did not necessitate further action. Because the patient’s cancer had metastasized before that radiograph, treatment then (or later) would not have changed the outcome.

VERDICT $850,000 New York verdict.

COMMENT Careful follow-up and diagnosis of chest radiograph abnormalities is paramount.

Yes, it was a stroke

WEAKNESS, NUMBNESS, AND TINGLING IN HIS RIGHT ARM prompted a 56-year-old man to visit his primary care physician. The physician sent the patient to the emergency department (ED) for testing because he believed the man was experiencing stroke-like symptoms. As the patient and his wife drove to the hospital, the physician faxed the patient’s medical records to the ED.

When the patient’s wife tried to give ED employees the physician’s orders for tests and tell them of the doctor’s concern about a stroke, they told her that all the beds were full and she should sit down and wait.

The patient was eventually evaluated as a low-priority patient with numbness in his right hand. The examining doctor ordered radiographs of the right wrist and discharged the patient with a diagnosis of carpal tunnel syndrome.

Twenty minutes later, a nurse left a message telling the patient to return to the hospital for the stroke-related tests that had been ordered by his primary care physician. An ED physician other than the one who first examined the patient performed the tests—except for a test of blood flow to the brain. The physician diagnosed stroke-like symptoms and requested a consultation with another physician, which never happened. The patient was discharged about 6 hours after his first discharge.

About 16 hours later, the patient suffered a stroke. Subsequent testing revealed an obstruction in the left carotid artery. The stroke resulted in permanent neurologic injury.

PLAINTIFF’S CLAIM No information about the plaintiff’s claim is available.

THE DEFENSE The defendants denied negligence and disputed the extent of the patient’s injuries.

VERDICT $1.123 million Maryland verdict.

COMMENT Coordination of care remains critical, particularly between our outpatient offices and the busy ED.

Missed dissecting aortic aneurysm proves fatal

A 43-YEAR-OLD MAN was admitted to the hospital complaining of severe chest pain, shortness of breath, sweating, and dry mouth. After being seen by several physicians, the patient suffered an aortic dissection, which caused bleeding in the wall of the aorta, an aortic rupture, and bleeding into the pericardium. He died 2 days later.

PLAINTIFF’S CLAIM The defendants failed to order tests to rule out a dissecting aortic aneurysm and did not include aortic dissection in the differential diagnosis. They failed to provide appropriate drug therapy to decrease cardiac impulse and lower the systolic blood pressure. They did not obtain an emergency cardiac consultation or admit the patient to a cardiovascular surgical intensive care unit.

THE DEFENSE The defendants denied negligence and claimed that nothing they did or failed to do contributed to the patient’s death.

VERDICT $250,000 Michigan settlement.

COMMENT Just yesterday, a malpractice lawyer presented me with a case very similar to this one: a patient with unexplained chest pain who died of a dissecting aneurysm. Remember, not all chest pain is caused by coronary artery disease.

Too-late cancer Dx blamed on neglected x-ray findings

A LONG-TERM CIGARETTE SMOKER IN HER 50s saw a physician in 2001 for symptoms of pneumonia. The doctor prescribed antibiotics and referred her to another facility for a chest radiograph.

Five days later, she returned to the physician’s office, where she was seen by another internist in the practice. The internist noted that the chest radiograph showed parenchymal densities in the right lung. Parenchymal densities had also showed up on 2 previous chest radiographs, but were more prevalent on the latest film. The internist advised the patient to finish her antibiotic regimen; he did not prescribe further tests or treatment.

Over the following 40 months, doctors in the patient’s medical group examined her 8 times. Each time she complained of impaired respiration. The internist believed that the symptoms were caused by asthma.

In 2004, the patient was diagnosed with stage IV cancer of the right lung, which had spread to her bones and was untreatable. She died several weeks later.

PLAINTIFF’S CLAIM A proper diagnosis in 2001 would have allowed the cancer to be cured. A computed tomography scan should have been performed and a pulmonologist consulted at that time.

THE DEFENSE Findings from the radiograph from 2001 did not necessitate further action. Because the patient’s cancer had metastasized before that radiograph, treatment then (or later) would not have changed the outcome.

VERDICT $850,000 New York verdict.

COMMENT Careful follow-up and diagnosis of chest radiograph abnormalities is paramount.

Yes, it was a stroke

WEAKNESS, NUMBNESS, AND TINGLING IN HIS RIGHT ARM prompted a 56-year-old man to visit his primary care physician. The physician sent the patient to the emergency department (ED) for testing because he believed the man was experiencing stroke-like symptoms. As the patient and his wife drove to the hospital, the physician faxed the patient’s medical records to the ED.

When the patient’s wife tried to give ED employees the physician’s orders for tests and tell them of the doctor’s concern about a stroke, they told her that all the beds were full and she should sit down and wait.

The patient was eventually evaluated as a low-priority patient with numbness in his right hand. The examining doctor ordered radiographs of the right wrist and discharged the patient with a diagnosis of carpal tunnel syndrome.

Twenty minutes later, a nurse left a message telling the patient to return to the hospital for the stroke-related tests that had been ordered by his primary care physician. An ED physician other than the one who first examined the patient performed the tests—except for a test of blood flow to the brain. The physician diagnosed stroke-like symptoms and requested a consultation with another physician, which never happened. The patient was discharged about 6 hours after his first discharge.

About 16 hours later, the patient suffered a stroke. Subsequent testing revealed an obstruction in the left carotid artery. The stroke resulted in permanent neurologic injury.

PLAINTIFF’S CLAIM No information about the plaintiff’s claim is available.

THE DEFENSE The defendants denied negligence and disputed the extent of the patient’s injuries.

VERDICT $1.123 million Maryland verdict.

COMMENT Coordination of care remains critical, particularly between our outpatient offices and the busy ED.

Failure to monitor INR leads to severe bleeding, disability

A MAN WITH A HISTORY OF DEEP VEIN THROMBOSIS was taking warfarin 10 mg every even day and 7.5 mg every odd day. His physician changed the warfarin dosage while the patient was taking ciprofloxacin, then resumed the original regimen once the patient finished taking the antibiotic.

No new prescriptions were written to confirm the change nor, the patient claimed, was a proper explanation of the new regimen provided. His international normalized ratio (INR) wasn’t checked after the dosage change.

After 2 weeks on the new warfarin dosage, the patient went to the emergency department (ED) complaining of groin pain and a change in urine color. Urinalysis found red blood cells too numerous to count. Although the patient told the ED staff he was taking warfarin, they didn’t check his INR. He was given a diagnosis of urinary tract infection (UTI) and discharged.

Three days later, the patient returned to the ED because of increased bleeding from his Foley catheter. Once again his INR wasn’t checked and he was discharged with a UTI diagnosis and a prescription for antibiotics. Two days afterwards, he was taken back to the hospital bleeding from all orifices. His INR was 75.

The patient spent a month in the hospital, most of it in the intensive care unit, followed by 3 months in a rehabilitation facility before returning home. He remained confined to a hospital bed.

PLAINTIFF’S CLAIM The physician and hospital were negligent for failing to instruct the patient regarding the change in warfarin dosage and neglecting to check his INR.

THE DEFENSE No information about the defense is available.

VERDICT $700,000 Maryland settlement.

COMMENT The management of anticoagulation has numerous pitfalls for the unwary. Careful monitoring can save lives—and lawsuits.

Rash and hives not taken seriously enough

A HISTORY OF 3 SEIZURES in a 7-year-old boy prompted a neurologist to prescribe valproic acid. The neurologist later added lamotrigine because of the child’s behavior problems. After taking both medications for 2 weeks, the child developed a rash, at which point the neurologist discontinued the lamotrigine and started diphenhydramine.

The following day, the child was brought to the ED with an itchy rash and hives on his torso and extremities. An allergic reaction was diagnosed and the child was discharged with instructions to take diphenhydramine along with acetaminophen and ibuprofen as needed. When informed of the ED visit, the neurologist requested a follow-up appointment in 4 weeks.

Two days later, the child was back in the ED because the rash had progressed to include redness and swelling of the face. Once again, he was discharged with a diagnosis of allergic reaction and instructions to take diphenhydramine and acetaminophen.

Two days afterward, the child was taken to a different ED, from which he was airlifted to a tertiary care center and admitted to the intensive care unit for treatment of Stevens-Johnson syndrome. The condition advanced to toxic epidermal necrolysis with sloughing of skin and the lining of the gastrointestinal tract. Several weeks later, the child died.

PLAINTIFF’S CLAIM The neurologist was negligent in prescribing lamotrigine for the behavior problem instead of referring the boy to a child psychologist. The lamotrigine dosage was excessive; the neurologist didn’t respond properly to the report of a rash.

The pharmacist was negligent in failing to contact the neurologist to discuss the excessive dosage. Discharging the child from the ED with a life-threatening drug reaction was unreasonable.

THE DEFENSE The defendants denied that they were negligent or caused the child’s death. They were prepared to present the histories of the parents, whose backgrounds included drug abuse, and state investigations regarding the care of the child.

VERDICT $1.55 million Washington settlement.

COMMENT When prescribing a drug with a potentially serious adverse effect, it’s always prudent to document patient education and follow-up thoroughly. Even though hindsight is 20/20, an “allergic reaction” in a patient on lamotrigine should raise red flags.

Delay in spotting compartment syndrome has permanent consequences

SEVERE NUMBNESS, TINGLING, AND PAIN IN HER LEFT CALF brought a 20-year-old woman to the ED. She couldn’t lift her left foot or bear weight on her left foot or leg. She reported awakening with the symptoms after a New Year’s Eve party the previous evening. After an examination, but no tests, she was discharged with a diagnosis of “floppy foot syndrome” and a prescription for a non-narcotic pain medication.

The young woman went to another ED the next day, complaining of continued pain and swelling in her left calf. She was admitted to the hospital for an orthopedic consultation, which resulted in a diagnosis of compartment syndrome. By that time, the patient had gone into renal failure from rhabdomyolysis caused by tissue breakdown. She underwent a fasciotomy, after which she required hemodialysis (until her kidney function returned) and rehabilitation. Damage to the nerves of her left calf and leg left her with permanent foot drop.

PLAINTIFF’S CLAIM The hospital was negligent in failing to diagnose compartment syndrome when the woman went to the ED. Proper diagnosis and treatment at that time would have prevented the nerve damage and foot drop.

THE DEFENSE No information about the defense is available.

VERDICT $750,000 Maryland settlement.

COMMENT Compartment syndrome can be challenging to recognize. Recently I have come across several allegations of malpractice for untimely diagnosis. Remember this important problem when faced with a patient with leg pain.

Multiple errors end in death from pneumonia

A 24-YEAR-OLD MAN WITH CHEST PAIN AND A COUGH went to his physician, who diagnosed chest wall pain and prescribed a narcotic pain reliever. The young man returned the next day complaining of increased chest pain. He said he’d been spitting up blood-stained sputum. He was perspiring and vomited in the doctor’s waiting room. The doctor diagnosed an upper respiratory infection and prescribed a cough syrup containing more narcotics.

Later that day the patient had a radiograph at a hospital. It revealed pneumonia. Shortly afterward, the hospital confirmed by fax with the doctor’s office that the doctor had received the results. The doctor didn’t read the radiograph results for 2 days.

After the doctor read the radiograph report, his office tried to contact the patient but misdialed his phone number, then made no further attempts at contact. The patient’s former wife found him at home unresponsive. He was admitted to the ED, where he died of pneumonia shortly thereafter.

PLAINTIFF’S CLAIM No information about the plaintiff’s claim is available.

THE DEFENSE No information about the defense is available.

VERDICT $1.85 million net verdict in Virginia.

COMMENT A cascade of mistakes (sometimes referred to as the Swiss cheese effect) occurs, and a preventable death results. Are you at risk for such an event? What fail-safe measures do you have in place in your practice?

Failure to monitor INR leads to severe bleeding, disability

A MAN WITH A HISTORY OF DEEP VEIN THROMBOSIS was taking warfarin 10 mg every even day and 7.5 mg every odd day. His physician changed the warfarin dosage while the patient was taking ciprofloxacin, then resumed the original regimen once the patient finished taking the antibiotic.

No new prescriptions were written to confirm the change nor, the patient claimed, was a proper explanation of the new regimen provided. His international normalized ratio (INR) wasn’t checked after the dosage change.

After 2 weeks on the new warfarin dosage, the patient went to the emergency department (ED) complaining of groin pain and a change in urine color. Urinalysis found red blood cells too numerous to count. Although the patient told the ED staff he was taking warfarin, they didn’t check his INR. He was given a diagnosis of urinary tract infection (UTI) and discharged.

Three days later, the patient returned to the ED because of increased bleeding from his Foley catheter. Once again his INR wasn’t checked and he was discharged with a UTI diagnosis and a prescription for antibiotics. Two days afterwards, he was taken back to the hospital bleeding from all orifices. His INR was 75.

The patient spent a month in the hospital, most of it in the intensive care unit, followed by 3 months in a rehabilitation facility before returning home. He remained confined to a hospital bed.

PLAINTIFF’S CLAIM The physician and hospital were negligent for failing to instruct the patient regarding the change in warfarin dosage and neglecting to check his INR.

THE DEFENSE No information about the defense is available.

VERDICT $700,000 Maryland settlement.

COMMENT The management of anticoagulation has numerous pitfalls for the unwary. Careful monitoring can save lives—and lawsuits.

Rash and hives not taken seriously enough

A HISTORY OF 3 SEIZURES in a 7-year-old boy prompted a neurologist to prescribe valproic acid. The neurologist later added lamotrigine because of the child’s behavior problems. After taking both medications for 2 weeks, the child developed a rash, at which point the neurologist discontinued the lamotrigine and started diphenhydramine.

The following day, the child was brought to the ED with an itchy rash and hives on his torso and extremities. An allergic reaction was diagnosed and the child was discharged with instructions to take diphenhydramine along with acetaminophen and ibuprofen as needed. When informed of the ED visit, the neurologist requested a follow-up appointment in 4 weeks.

Two days later, the child was back in the ED because the rash had progressed to include redness and swelling of the face. Once again, he was discharged with a diagnosis of allergic reaction and instructions to take diphenhydramine and acetaminophen.

Two days afterward, the child was taken to a different ED, from which he was airlifted to a tertiary care center and admitted to the intensive care unit for treatment of Stevens-Johnson syndrome. The condition advanced to toxic epidermal necrolysis with sloughing of skin and the lining of the gastrointestinal tract. Several weeks later, the child died.

PLAINTIFF’S CLAIM The neurologist was negligent in prescribing lamotrigine for the behavior problem instead of referring the boy to a child psychologist. The lamotrigine dosage was excessive; the neurologist didn’t respond properly to the report of a rash.

The pharmacist was negligent in failing to contact the neurologist to discuss the excessive dosage. Discharging the child from the ED with a life-threatening drug reaction was unreasonable.

THE DEFENSE The defendants denied that they were negligent or caused the child’s death. They were prepared to present the histories of the parents, whose backgrounds included drug abuse, and state investigations regarding the care of the child.

VERDICT $1.55 million Washington settlement.

COMMENT When prescribing a drug with a potentially serious adverse effect, it’s always prudent to document patient education and follow-up thoroughly. Even though hindsight is 20/20, an “allergic reaction” in a patient on lamotrigine should raise red flags.

Delay in spotting compartment syndrome has permanent consequences

SEVERE NUMBNESS, TINGLING, AND PAIN IN HER LEFT CALF brought a 20-year-old woman to the ED. She couldn’t lift her left foot or bear weight on her left foot or leg. She reported awakening with the symptoms after a New Year’s Eve party the previous evening. After an examination, but no tests, she was discharged with a diagnosis of “floppy foot syndrome” and a prescription for a non-narcotic pain medication.

The young woman went to another ED the next day, complaining of continued pain and swelling in her left calf. She was admitted to the hospital for an orthopedic consultation, which resulted in a diagnosis of compartment syndrome. By that time, the patient had gone into renal failure from rhabdomyolysis caused by tissue breakdown. She underwent a fasciotomy, after which she required hemodialysis (until her kidney function returned) and rehabilitation. Damage to the nerves of her left calf and leg left her with permanent foot drop.

PLAINTIFF’S CLAIM The hospital was negligent in failing to diagnose compartment syndrome when the woman went to the ED. Proper diagnosis and treatment at that time would have prevented the nerve damage and foot drop.

THE DEFENSE No information about the defense is available.

VERDICT $750,000 Maryland settlement.

COMMENT Compartment syndrome can be challenging to recognize. Recently I have come across several allegations of malpractice for untimely diagnosis. Remember this important problem when faced with a patient with leg pain.

Multiple errors end in death from pneumonia

A 24-YEAR-OLD MAN WITH CHEST PAIN AND A COUGH went to his physician, who diagnosed chest wall pain and prescribed a narcotic pain reliever. The young man returned the next day complaining of increased chest pain. He said he’d been spitting up blood-stained sputum. He was perspiring and vomited in the doctor’s waiting room. The doctor diagnosed an upper respiratory infection and prescribed a cough syrup containing more narcotics.

Later that day the patient had a radiograph at a hospital. It revealed pneumonia. Shortly afterward, the hospital confirmed by fax with the doctor’s office that the doctor had received the results. The doctor didn’t read the radiograph results for 2 days.

After the doctor read the radiograph report, his office tried to contact the patient but misdialed his phone number, then made no further attempts at contact. The patient’s former wife found him at home unresponsive. He was admitted to the ED, where he died of pneumonia shortly thereafter.

PLAINTIFF’S CLAIM No information about the plaintiff’s claim is available.

THE DEFENSE No information about the defense is available.

VERDICT $1.85 million net verdict in Virginia.

COMMENT A cascade of mistakes (sometimes referred to as the Swiss cheese effect) occurs, and a preventable death results. Are you at risk for such an event? What fail-safe measures do you have in place in your practice?

Failure to monitor INR leads to severe bleeding, disability

A MAN WITH A HISTORY OF DEEP VEIN THROMBOSIS was taking warfarin 10 mg every even day and 7.5 mg every odd day. His physician changed the warfarin dosage while the patient was taking ciprofloxacin, then resumed the original regimen once the patient finished taking the antibiotic.

No new prescriptions were written to confirm the change nor, the patient claimed, was a proper explanation of the new regimen provided. His international normalized ratio (INR) wasn’t checked after the dosage change.

After 2 weeks on the new warfarin dosage, the patient went to the emergency department (ED) complaining of groin pain and a change in urine color. Urinalysis found red blood cells too numerous to count. Although the patient told the ED staff he was taking warfarin, they didn’t check his INR. He was given a diagnosis of urinary tract infection (UTI) and discharged.

Three days later, the patient returned to the ED because of increased bleeding from his Foley catheter. Once again his INR wasn’t checked and he was discharged with a UTI diagnosis and a prescription for antibiotics. Two days afterwards, he was taken back to the hospital bleeding from all orifices. His INR was 75.

The patient spent a month in the hospital, most of it in the intensive care unit, followed by 3 months in a rehabilitation facility before returning home. He remained confined to a hospital bed.

PLAINTIFF’S CLAIM The physician and hospital were negligent for failing to instruct the patient regarding the change in warfarin dosage and neglecting to check his INR.

THE DEFENSE No information about the defense is available.

VERDICT $700,000 Maryland settlement.

COMMENT The management of anticoagulation has numerous pitfalls for the unwary. Careful monitoring can save lives—and lawsuits.

Rash and hives not taken seriously enough

A HISTORY OF 3 SEIZURES in a 7-year-old boy prompted a neurologist to prescribe valproic acid. The neurologist later added lamotrigine because of the child’s behavior problems. After taking both medications for 2 weeks, the child developed a rash, at which point the neurologist discontinued the lamotrigine and started diphenhydramine.

The following day, the child was brought to the ED with an itchy rash and hives on his torso and extremities. An allergic reaction was diagnosed and the child was discharged with instructions to take diphenhydramine along with acetaminophen and ibuprofen as needed. When informed of the ED visit, the neurologist requested a follow-up appointment in 4 weeks.

Two days later, the child was back in the ED because the rash had progressed to include redness and swelling of the face. Once again, he was discharged with a diagnosis of allergic reaction and instructions to take diphenhydramine and acetaminophen.

Two days afterward, the child was taken to a different ED, from which he was airlifted to a tertiary care center and admitted to the intensive care unit for treatment of Stevens-Johnson syndrome. The condition advanced to toxic epidermal necrolysis with sloughing of skin and the lining of the gastrointestinal tract. Several weeks later, the child died.

PLAINTIFF’S CLAIM The neurologist was negligent in prescribing lamotrigine for the behavior problem instead of referring the boy to a child psychologist. The lamotrigine dosage was excessive; the neurologist didn’t respond properly to the report of a rash.

The pharmacist was negligent in failing to contact the neurologist to discuss the excessive dosage. Discharging the child from the ED with a life-threatening drug reaction was unreasonable.

THE DEFENSE The defendants denied that they were negligent or caused the child’s death. They were prepared to present the histories of the parents, whose backgrounds included drug abuse, and state investigations regarding the care of the child.

VERDICT $1.55 million Washington settlement.

COMMENT When prescribing a drug with a potentially serious adverse effect, it’s always prudent to document patient education and follow-up thoroughly. Even though hindsight is 20/20, an “allergic reaction” in a patient on lamotrigine should raise red flags.

Delay in spotting compartment syndrome has permanent consequences

SEVERE NUMBNESS, TINGLING, AND PAIN IN HER LEFT CALF brought a 20-year-old woman to the ED. She couldn’t lift her left foot or bear weight on her left foot or leg. She reported awakening with the symptoms after a New Year’s Eve party the previous evening. After an examination, but no tests, she was discharged with a diagnosis of “floppy foot syndrome” and a prescription for a non-narcotic pain medication.

The young woman went to another ED the next day, complaining of continued pain and swelling in her left calf. She was admitted to the hospital for an orthopedic consultation, which resulted in a diagnosis of compartment syndrome. By that time, the patient had gone into renal failure from rhabdomyolysis caused by tissue breakdown. She underwent a fasciotomy, after which she required hemodialysis (until her kidney function returned) and rehabilitation. Damage to the nerves of her left calf and leg left her with permanent foot drop.

PLAINTIFF’S CLAIM The hospital was negligent in failing to diagnose compartment syndrome when the woman went to the ED. Proper diagnosis and treatment at that time would have prevented the nerve damage and foot drop.

THE DEFENSE No information about the defense is available.

VERDICT $750,000 Maryland settlement.

COMMENT Compartment syndrome can be challenging to recognize. Recently I have come across several allegations of malpractice for untimely diagnosis. Remember this important problem when faced with a patient with leg pain.

Multiple errors end in death from pneumonia

A 24-YEAR-OLD MAN WITH CHEST PAIN AND A COUGH went to his physician, who diagnosed chest wall pain and prescribed a narcotic pain reliever. The young man returned the next day complaining of increased chest pain. He said he’d been spitting up blood-stained sputum. He was perspiring and vomited in the doctor’s waiting room. The doctor diagnosed an upper respiratory infection and prescribed a cough syrup containing more narcotics.

Later that day the patient had a radiograph at a hospital. It revealed pneumonia. Shortly afterward, the hospital confirmed by fax with the doctor’s office that the doctor had received the results. The doctor didn’t read the radiograph results for 2 days.

After the doctor read the radiograph report, his office tried to contact the patient but misdialed his phone number, then made no further attempts at contact. The patient’s former wife found him at home unresponsive. He was admitted to the ED, where he died of pneumonia shortly thereafter.

PLAINTIFF’S CLAIM No information about the plaintiff’s claim is available.

THE DEFENSE No information about the defense is available.

VERDICT $1.85 million net verdict in Virginia.

COMMENT A cascade of mistakes (sometimes referred to as the Swiss cheese effect) occurs, and a preventable death results. Are you at risk for such an event? What fail-safe measures do you have in place in your practice?

CT scan wasn’t ordered, diagnosis was delayed

A 9-YEAR-OLD BOY fell and hit the left side of his head on a coffee table while playing at a friend’s house. His father, who was present, applied ice to the child’s head and took him home. The child subsequently vomited and complained that his jaw hurt. He was given ibuprofen and taken to the emergency department (ED).

The ED physician determined that he needed stitches in his left ear. After the ear was sutured, the child was discharged, even though he had vomited in the examination room.

The child vomited again around midnight, then awoke around 2:30 am and went back to sleep. Around 5:00 am he vomited again and was gasping for air and breathing with difficulty. A call to 911 resulted in the child being airlifted to a trauma center, where a computed tomography (CT) scan revealed a massive hematoma. The brain was herniated and protruding from the bottom of the skull.

After undergoing emergency surgery, the patient spent 3 days in the ICU, some of that time on a ventilator, and several weeks in the hospital. After discharge, he underwent intensive therapy to relearn how to eat and talk. He suffered cognitive losses, emotional difficulties, left-sided weakness, and hemiparesis.

PLAINTIFF’S CLAIM The ED physician should have ordered a CT scan, which would have revealed the hematoma and prompted emergency surgery to relieve the pressure. The physician didn’t tell the parents how to observe the child for a head injury.

THE DEFENSE A CT scan wasn’t necessary. The patient appeared fine in the ED and was neurologically intact with a perfect Glasgow coma score of 15. Hematoma was a low possibility. The parents were told to watch the child and received head injury instructions.

VERDICT $2.4 million Ohio verdict.

COMMENT A variety of decision support tools would suggest CT in the face of vomiting 2 or more times, even with a Glasgow coma score of 15 (see the discussion of the Canadian CT Head Rule and New Orleans Criteria at http://guidelines.gov/content.aspx?id=136&search=neuroimaging+children+head+trauma). Clinical judgment alone may be insufficient to detect potentially catastrophic injury—particularly in younger children.

Stroke symptoms blamed on food poisoning

AN ISCHEMIC, LEFT-SIDED STROKE with left inferior frontoparietal lobe, occipital lobe, and cerebellar infarcts left a 33-year-old man with unclear speech, difficulty walking, major headache, and other stroke symptoms. He was taken by ambulance to a hospital within 1 hour of the onset of symptoms.

Hospital staff diagnosed food poisoning and discharged the man even though he couldn’t walk or speak coherently. The patient suffered brain damage resulting in cognitive impairment with memory loss and confusion.

PLAINTIFF’S CLAIM A proper neurologic work-up wasn’t done; hospital staff should have consulted a neurologist. The patient should have received tissue plasminogen activator (t-PA).

THE DEFENSE The history provided at the hospital mentioned that the patient had eaten chocolate cake before the onset of symptoms; the symptoms weren’t significant enough to consider stroke in the differential diagnosis. The plaintiff couldn’t prove that his condition would have been significantly better even if he’d received t-PA.

VERDICT $2.1 million California arbitration award.

COMMENT This story is difficult to believe—food poisoning causing trouble speaking, difficulty walking, and a headache?! One can only wonder whether better documentation of medical decision making would have produced a more understandable response.

CT scan wasn’t ordered, diagnosis was delayed

A 9-YEAR-OLD BOY fell and hit the left side of his head on a coffee table while playing at a friend’s house. His father, who was present, applied ice to the child’s head and took him home. The child subsequently vomited and complained that his jaw hurt. He was given ibuprofen and taken to the emergency department (ED).

The ED physician determined that he needed stitches in his left ear. After the ear was sutured, the child was discharged, even though he had vomited in the examination room.

The child vomited again around midnight, then awoke around 2:30 am and went back to sleep. Around 5:00 am he vomited again and was gasping for air and breathing with difficulty. A call to 911 resulted in the child being airlifted to a trauma center, where a computed tomography (CT) scan revealed a massive hematoma. The brain was herniated and protruding from the bottom of the skull.

After undergoing emergency surgery, the patient spent 3 days in the ICU, some of that time on a ventilator, and several weeks in the hospital. After discharge, he underwent intensive therapy to relearn how to eat and talk. He suffered cognitive losses, emotional difficulties, left-sided weakness, and hemiparesis.

PLAINTIFF’S CLAIM The ED physician should have ordered a CT scan, which would have revealed the hematoma and prompted emergency surgery to relieve the pressure. The physician didn’t tell the parents how to observe the child for a head injury.

THE DEFENSE A CT scan wasn’t necessary. The patient appeared fine in the ED and was neurologically intact with a perfect Glasgow coma score of 15. Hematoma was a low possibility. The parents were told to watch the child and received head injury instructions.

VERDICT $2.4 million Ohio verdict.

COMMENT A variety of decision support tools would suggest CT in the face of vomiting 2 or more times, even with a Glasgow coma score of 15 (see the discussion of the Canadian CT Head Rule and New Orleans Criteria at http://guidelines.gov/content.aspx?id=136&search=neuroimaging+children+head+trauma). Clinical judgment alone may be insufficient to detect potentially catastrophic injury—particularly in younger children.

Stroke symptoms blamed on food poisoning

AN ISCHEMIC, LEFT-SIDED STROKE with left inferior frontoparietal lobe, occipital lobe, and cerebellar infarcts left a 33-year-old man with unclear speech, difficulty walking, major headache, and other stroke symptoms. He was taken by ambulance to a hospital within 1 hour of the onset of symptoms.

Hospital staff diagnosed food poisoning and discharged the man even though he couldn’t walk or speak coherently. The patient suffered brain damage resulting in cognitive impairment with memory loss and confusion.

PLAINTIFF’S CLAIM A proper neurologic work-up wasn’t done; hospital staff should have consulted a neurologist. The patient should have received tissue plasminogen activator (t-PA).

THE DEFENSE The history provided at the hospital mentioned that the patient had eaten chocolate cake before the onset of symptoms; the symptoms weren’t significant enough to consider stroke in the differential diagnosis. The plaintiff couldn’t prove that his condition would have been significantly better even if he’d received t-PA.

VERDICT $2.1 million California arbitration award.

COMMENT This story is difficult to believe—food poisoning causing trouble speaking, difficulty walking, and a headache?! One can only wonder whether better documentation of medical decision making would have produced a more understandable response.

CT scan wasn’t ordered, diagnosis was delayed

A 9-YEAR-OLD BOY fell and hit the left side of his head on a coffee table while playing at a friend’s house. His father, who was present, applied ice to the child’s head and took him home. The child subsequently vomited and complained that his jaw hurt. He was given ibuprofen and taken to the emergency department (ED).

The ED physician determined that he needed stitches in his left ear. After the ear was sutured, the child was discharged, even though he had vomited in the examination room.

The child vomited again around midnight, then awoke around 2:30 am and went back to sleep. Around 5:00 am he vomited again and was gasping for air and breathing with difficulty. A call to 911 resulted in the child being airlifted to a trauma center, where a computed tomography (CT) scan revealed a massive hematoma. The brain was herniated and protruding from the bottom of the skull.

After undergoing emergency surgery, the patient spent 3 days in the ICU, some of that time on a ventilator, and several weeks in the hospital. After discharge, he underwent intensive therapy to relearn how to eat and talk. He suffered cognitive losses, emotional difficulties, left-sided weakness, and hemiparesis.

PLAINTIFF’S CLAIM The ED physician should have ordered a CT scan, which would have revealed the hematoma and prompted emergency surgery to relieve the pressure. The physician didn’t tell the parents how to observe the child for a head injury.

THE DEFENSE A CT scan wasn’t necessary. The patient appeared fine in the ED and was neurologically intact with a perfect Glasgow coma score of 15. Hematoma was a low possibility. The parents were told to watch the child and received head injury instructions.

VERDICT $2.4 million Ohio verdict.

COMMENT A variety of decision support tools would suggest CT in the face of vomiting 2 or more times, even with a Glasgow coma score of 15 (see the discussion of the Canadian CT Head Rule and New Orleans Criteria at http://guidelines.gov/content.aspx?id=136&search=neuroimaging+children+head+trauma). Clinical judgment alone may be insufficient to detect potentially catastrophic injury—particularly in younger children.

Stroke symptoms blamed on food poisoning

AN ISCHEMIC, LEFT-SIDED STROKE with left inferior frontoparietal lobe, occipital lobe, and cerebellar infarcts left a 33-year-old man with unclear speech, difficulty walking, major headache, and other stroke symptoms. He was taken by ambulance to a hospital within 1 hour of the onset of symptoms.

Hospital staff diagnosed food poisoning and discharged the man even though he couldn’t walk or speak coherently. The patient suffered brain damage resulting in cognitive impairment with memory loss and confusion.

PLAINTIFF’S CLAIM A proper neurologic work-up wasn’t done; hospital staff should have consulted a neurologist. The patient should have received tissue plasminogen activator (t-PA).

THE DEFENSE The history provided at the hospital mentioned that the patient had eaten chocolate cake before the onset of symptoms; the symptoms weren’t significant enough to consider stroke in the differential diagnosis. The plaintiff couldn’t prove that his condition would have been significantly better even if he’d received t-PA.

VERDICT $2.1 million California arbitration award.

COMMENT This story is difficult to believe—food poisoning causing trouble speaking, difficulty walking, and a headache?! One can only wonder whether better documentation of medical decision making would have produced a more understandable response.

Would a colonoscopy have made a difference?

ABDOMINAL PAIN, BURNING AND CRAMPING, and inability to eat led a 31-year-old man to visit his primary care physician. A nurse practitioner (NP) examined the man, prescribed ranitidine, and gave him an appointment for a complete physical the following month.

The patient’s history, as provided during the physical exam, included tobacco chewing, high coffee intake, and occasional abdominal pain and increased stools. He said that his mother had been diagnosed with colon cancer at 54 years of age. Neither a rectal exam nor colonoscopy was performed.

The NP substituted pantoprazole for ranitidine and ordered an upper gastrointestinal series with contrast to rule out gastritis or an ulcer. The results were negative. They were given to the primary care physician, who never saw the patient or reviewed his chart.

A month later, the patient saw a nurse for continued problems eating, despite symptom relief on pantoprazole. The nurse stuck with a diagnosis of gastritis and told the patient to follow up in 6 months and to call if problems arose.

Four months later, the patient returned complaining of worsening stomach cramps and burning. The NP changed his medication to lansoprazole and set up an appointment in 3 months with a gastroenterologist.

The patient returned a month afterward reporting increasing pain and loose stools. The GI consult was moved to an earlier date after discussion with the primary care physician, but the patient went to an emergency room before the scheduled consultation.

An abdominal computed tomography scan and colonoscopy revealed near obstruction of the right side of the colon by a stage IV tumor and metastasis to the peritoneum and lymph nodes. The patient underwent immediate surgery, followed by chemotherapy, more surgery, and a cingulotomy for pain relief. He died about 2 years later.

PLAINTIFF’S CLAIM The NP should have performed a rectal exam, obtained stool for occult blood tests, or ordered a colonoscopy. The patient’s chances of survival would have been better if he’d been diagnosed and treated earlier.

THE DEFENSE The patient didn’t need a colonoscopy; his tobacco chewing and excessive coffee drinking explained his eating difficulties. The NP was properly supervised and there was no independent duty to review individual patient charts and sign off on them regularly. The patient was already at stage IV when he was seen initially; nothing could have changed the treatment or outcome.

VERDICT $4.65 million Massachusetts verdict.

COMMENT Regardless of the medical facts of this case, supervision of staff and other health professionals is tricky. Clear job descriptions, protocols for care, and expectations for consultation will help avoid legal pitfalls.

Suicide blamed on failure to diagnose bipolar disorder

A 29-YEAR-OLD WOMAN spent about 6 months under the care of a psychiatrist, during which time she was diagnosed with severe depression. The psychiatrist prescribed a series of selective serotonin reuptake inhibitors (SSRIs). The patient took the medications as prescribed but eventually committed suicide.

PLAINTIFF’S CLAIM The psychiatrist misdiagnosed the patient; the patient’s depression was one symptom of bipolar disorder. The US Food and Drug Administration has warned that SSRIs increase the risk of suicide in patients with bipolar disorder.

THE DEFENSE The last time the psychiatrist saw the patient was more than 30 days before her death; the diagnosis of depression was correct.

VERDICT $175,000 Michigan settlement.

COMMENT Every patient with depressive features should be screened for bipolar disorder. As this case illustrates, the medical and legal consequences can be profound.

Would a colonoscopy have made a difference?

ABDOMINAL PAIN, BURNING AND CRAMPING, and inability to eat led a 31-year-old man to visit his primary care physician. A nurse practitioner (NP) examined the man, prescribed ranitidine, and gave him an appointment for a complete physical the following month.

The patient’s history, as provided during the physical exam, included tobacco chewing, high coffee intake, and occasional abdominal pain and increased stools. He said that his mother had been diagnosed with colon cancer at 54 years of age. Neither a rectal exam nor colonoscopy was performed.

The NP substituted pantoprazole for ranitidine and ordered an upper gastrointestinal series with contrast to rule out gastritis or an ulcer. The results were negative. They were given to the primary care physician, who never saw the patient or reviewed his chart.

A month later, the patient saw a nurse for continued problems eating, despite symptom relief on pantoprazole. The nurse stuck with a diagnosis of gastritis and told the patient to follow up in 6 months and to call if problems arose.

Four months later, the patient returned complaining of worsening stomach cramps and burning. The NP changed his medication to lansoprazole and set up an appointment in 3 months with a gastroenterologist.

The patient returned a month afterward reporting increasing pain and loose stools. The GI consult was moved to an earlier date after discussion with the primary care physician, but the patient went to an emergency room before the scheduled consultation.

An abdominal computed tomography scan and colonoscopy revealed near obstruction of the right side of the colon by a stage IV tumor and metastasis to the peritoneum and lymph nodes. The patient underwent immediate surgery, followed by chemotherapy, more surgery, and a cingulotomy for pain relief. He died about 2 years later.

PLAINTIFF’S CLAIM The NP should have performed a rectal exam, obtained stool for occult blood tests, or ordered a colonoscopy. The patient’s chances of survival would have been better if he’d been diagnosed and treated earlier.

THE DEFENSE The patient didn’t need a colonoscopy; his tobacco chewing and excessive coffee drinking explained his eating difficulties. The NP was properly supervised and there was no independent duty to review individual patient charts and sign off on them regularly. The patient was already at stage IV when he was seen initially; nothing could have changed the treatment or outcome.

VERDICT $4.65 million Massachusetts verdict.

COMMENT Regardless of the medical facts of this case, supervision of staff and other health professionals is tricky. Clear job descriptions, protocols for care, and expectations for consultation will help avoid legal pitfalls.

Suicide blamed on failure to diagnose bipolar disorder

A 29-YEAR-OLD WOMAN spent about 6 months under the care of a psychiatrist, during which time she was diagnosed with severe depression. The psychiatrist prescribed a series of selective serotonin reuptake inhibitors (SSRIs). The patient took the medications as prescribed but eventually committed suicide.

PLAINTIFF’S CLAIM The psychiatrist misdiagnosed the patient; the patient’s depression was one symptom of bipolar disorder. The US Food and Drug Administration has warned that SSRIs increase the risk of suicide in patients with bipolar disorder.

THE DEFENSE The last time the psychiatrist saw the patient was more than 30 days before her death; the diagnosis of depression was correct.

VERDICT $175,000 Michigan settlement.

COMMENT Every patient with depressive features should be screened for bipolar disorder. As this case illustrates, the medical and legal consequences can be profound.

Would a colonoscopy have made a difference?

ABDOMINAL PAIN, BURNING AND CRAMPING, and inability to eat led a 31-year-old man to visit his primary care physician. A nurse practitioner (NP) examined the man, prescribed ranitidine, and gave him an appointment for a complete physical the following month.

The patient’s history, as provided during the physical exam, included tobacco chewing, high coffee intake, and occasional abdominal pain and increased stools. He said that his mother had been diagnosed with colon cancer at 54 years of age. Neither a rectal exam nor colonoscopy was performed.

The NP substituted pantoprazole for ranitidine and ordered an upper gastrointestinal series with contrast to rule out gastritis or an ulcer. The results were negative. They were given to the primary care physician, who never saw the patient or reviewed his chart.

A month later, the patient saw a nurse for continued problems eating, despite symptom relief on pantoprazole. The nurse stuck with a diagnosis of gastritis and told the patient to follow up in 6 months and to call if problems arose.

Four months later, the patient returned complaining of worsening stomach cramps and burning. The NP changed his medication to lansoprazole and set up an appointment in 3 months with a gastroenterologist.

The patient returned a month afterward reporting increasing pain and loose stools. The GI consult was moved to an earlier date after discussion with the primary care physician, but the patient went to an emergency room before the scheduled consultation.

An abdominal computed tomography scan and colonoscopy revealed near obstruction of the right side of the colon by a stage IV tumor and metastasis to the peritoneum and lymph nodes. The patient underwent immediate surgery, followed by chemotherapy, more surgery, and a cingulotomy for pain relief. He died about 2 years later.

PLAINTIFF’S CLAIM The NP should have performed a rectal exam, obtained stool for occult blood tests, or ordered a colonoscopy. The patient’s chances of survival would have been better if he’d been diagnosed and treated earlier.

THE DEFENSE The patient didn’t need a colonoscopy; his tobacco chewing and excessive coffee drinking explained his eating difficulties. The NP was properly supervised and there was no independent duty to review individual patient charts and sign off on them regularly. The patient was already at stage IV when he was seen initially; nothing could have changed the treatment or outcome.

VERDICT $4.65 million Massachusetts verdict.

COMMENT Regardless of the medical facts of this case, supervision of staff and other health professionals is tricky. Clear job descriptions, protocols for care, and expectations for consultation will help avoid legal pitfalls.

Suicide blamed on failure to diagnose bipolar disorder

A 29-YEAR-OLD WOMAN spent about 6 months under the care of a psychiatrist, during which time she was diagnosed with severe depression. The psychiatrist prescribed a series of selective serotonin reuptake inhibitors (SSRIs). The patient took the medications as prescribed but eventually committed suicide.

PLAINTIFF’S CLAIM The psychiatrist misdiagnosed the patient; the patient’s depression was one symptom of bipolar disorder. The US Food and Drug Administration has warned that SSRIs increase the risk of suicide in patients with bipolar disorder.

THE DEFENSE The last time the psychiatrist saw the patient was more than 30 days before her death; the diagnosis of depression was correct.

VERDICT $175,000 Michigan settlement.

COMMENT Every patient with depressive features should be screened for bipolar disorder. As this case illustrates, the medical and legal consequences can be profound.

Birth control prescription blamed for stroke

A 29-YEAR-OLD WOMAN SUFFERED A BLOOD CLOT in her leg. Her family physician advised her to start taking aspirin, which she did, and counseled her to use birth control that didn’t contain estrogen. She was taking norgestimate/ ethinyl estradiol at the time of the clot.

The woman subsequently went to an obstetrician-gynecologist (ob-gyn), whom she said she told about her family physician’s advice to avoid estrogen-containing birth control medication. The ob-gyn prescribed and inserted an etonogestrel/ethinyl estradiol vaginal ring.

A few months later the patient was hospitalized with severe headaches. She had blood clots in her brain and had suffered a stroke, which affected her speech and executive functions.

PLAINTIFF’S CLAIM The ob-gyn was negligent in prescribing the vaginal ring.

THE DEFENSE The cause of the first clot was an injury; the vaginal ring didn’t cause the second clot and stroke.

VERDICT $523,000 Georgia verdict.

COMMENT A comprehensive history, and clear documentation of communicating the potential risks of therapy, might have prevented this judgment.

Elevated PSA without referral delays diagnosis

ROUTINE BLOOD WORK before orthopedic surgery revealed an elevated prostate-specific antigen (PSA) of 7.4 in a 53-year-old man. A medical assistant who was directed to refer the patient to a urologist didn’t do so. Widespread metastatic prostate cancer was diagnosed 18 months later.

PLAINTIFF’S CLAIM Diagnosing the cancer 18 months earlier would have given the patient a >50% chance of 5-year survival. Because of the delay, he was terminal. The clinic was negligent in having no written procedure or system for tracking adverse lab test results.

THE DEFENSE The patient already had metastatic disease when the PSA level was discovered and would have required the same treatment.

VERDICT $1 million Washington settlement.

COMMENT A clear system for tracking test results is imperative in today’s litigious society.

Removal of mole without follow-up leads to death

A MOLE ON THE UPPER BACK prompted a 26-year-old man to visit a dermatologist, who performed a complete excision. The pathologist who examined the excised tissue suggested that the patient return for follow-up. During the next 6 months, the patient saw the dermatologist twice but didn’t receive proper follow-up.

Two years later, the patient noticed a suspicious area on his back near the scar from the excision. A hospital biopsy resulted in a diagnosis of metastatic melanoma. A review of the slides from the original biopsy found “melanoma, superficial spreading type, invasive to a depth of a minimum of 1.0 mm anatomic level IV, extending to inked deep resection margin.”

The patient underwent a wide local excision and was given a diagnosis of stage III melanoma. The patient underwent neck and back radiation and high-dose treatment with alpha interferon, followed by high-dose interleukin-2 and chemotherapy. Nevertheless, the patient died.

PLAINTIFF’S CLAIM The dermatologist’s office had no system to contact the patient when he didn’t return. The chances for cure would have been between 73% and 94% if the melanoma had been diagnosed at the time of the original excision.

THE DEFENSE No information about the defense is available.

VERDICT $1.7 million Massachusetts settlement.

COMMENT Failure to follow up on abnormal results is a potentially preventable cause of malpractice. Do you have a mechanism to track such testing?

Suggestive symptoms, but no Dx until it was too late

A 42-YEAR-OLD WOMAN went to the hospital in February for chest pain, dizziness, and shortness of breath. The emergency room physician diagnosed sinusitis and bronchitis and discharged the patient in stable condition. In April, the woman visited her primary care physician complaining of fatigue and shortness of breath. She claimed that her physician knew about the February emergency room visit. Later in April, she again went to her physician with shortness of breath; in July, she reported an irregular heart rhythm.

In October, the patient was found unresponsive after suffering cardiorespiratory arrest, hypoxic ischemic brain injury, and static encephalopathy. She has since been in a vegetative state.

PLAINTIFF’S CLAIM The patient had gone to her primary care physician many times during the 2 years before her emergency room visit with complaints suggesting an underlying cardiac condition, including shortness of breath, dizziness, light-headedness, vertigo, chest tightness, fatigue, and an irregular heart rhythm. The defendants were negligent in failing to diagnose the patient’s condition and provide proper treatment, failing to order proper diagnostic testing, and failing to perform a cardiac workup.

THE DEFENSE No negligence occurred.

VERDICT $6.3 million Florida verdict.

COMMENT Comprehensive documentation, including your medical decision making, can help prevent multimillion dollar judgments.

A serendipitous finding—to no avail

A FALL ON THE ICE sent a 74-year-old woman to the hospital with a fractured ankle. A preoperative chest radiograph taken before open reduction and internal fixation to repair the fracture showed a 2-cm nodular opacity in the right upper hemithorax. The radiologist recommended a computed tomography scan to rule out lung cancer, but the treating internists didn’t order a scan or refer the patient for biopsy.

The nodule appeared again on a second radiograph taken 2 days later. The patient wasn’t informed, and the attending internist at the time didn’t order follow-up testing or refer the patient to a specialist. The attending physicians continued to treat the patient without further testing or referral for the nodule.

Two years after the fracture, the patient was admitted to the hospital with complaints of sweating and shortness of breath. A chest radiograph showed pneumonia and the previously noted nodule. The patient was diagnosed with metastatic, inoperable small-cell lung cancer. She died after receiving extensive chemotherapy and radiation.

PLAINTIFF’S CLAIM The doctors were negligent in failing to diagnose and treat the lung cancer in a timely manner.

THE DEFENSE No information about the defense is available.

VERDICT $325,000 Michigan settlement.

COMMENT Could this happen to you? How many times have you serendipitously noted an abnormal result that was not followed up adequately?

Birth control prescription blamed for stroke

A 29-YEAR-OLD WOMAN SUFFERED A BLOOD CLOT in her leg. Her family physician advised her to start taking aspirin, which she did, and counseled her to use birth control that didn’t contain estrogen. She was taking norgestimate/ ethinyl estradiol at the time of the clot.

The woman subsequently went to an obstetrician-gynecologist (ob-gyn), whom she said she told about her family physician’s advice to avoid estrogen-containing birth control medication. The ob-gyn prescribed and inserted an etonogestrel/ethinyl estradiol vaginal ring.

A few months later the patient was hospitalized with severe headaches. She had blood clots in her brain and had suffered a stroke, which affected her speech and executive functions.

PLAINTIFF’S CLAIM The ob-gyn was negligent in prescribing the vaginal ring.

THE DEFENSE The cause of the first clot was an injury; the vaginal ring didn’t cause the second clot and stroke.

VERDICT $523,000 Georgia verdict.

COMMENT A comprehensive history, and clear documentation of communicating the potential risks of therapy, might have prevented this judgment.

Elevated PSA without referral delays diagnosis

ROUTINE BLOOD WORK before orthopedic surgery revealed an elevated prostate-specific antigen (PSA) of 7.4 in a 53-year-old man. A medical assistant who was directed to refer the patient to a urologist didn’t do so. Widespread metastatic prostate cancer was diagnosed 18 months later.

PLAINTIFF’S CLAIM Diagnosing the cancer 18 months earlier would have given the patient a >50% chance of 5-year survival. Because of the delay, he was terminal. The clinic was negligent in having no written procedure or system for tracking adverse lab test results.

THE DEFENSE The patient already had metastatic disease when the PSA level was discovered and would have required the same treatment.

VERDICT $1 million Washington settlement.

COMMENT A clear system for tracking test results is imperative in today’s litigious society.

Removal of mole without follow-up leads to death

A MOLE ON THE UPPER BACK prompted a 26-year-old man to visit a dermatologist, who performed a complete excision. The pathologist who examined the excised tissue suggested that the patient return for follow-up. During the next 6 months, the patient saw the dermatologist twice but didn’t receive proper follow-up.

Two years later, the patient noticed a suspicious area on his back near the scar from the excision. A hospital biopsy resulted in a diagnosis of metastatic melanoma. A review of the slides from the original biopsy found “melanoma, superficial spreading type, invasive to a depth of a minimum of 1.0 mm anatomic level IV, extending to inked deep resection margin.”

The patient underwent a wide local excision and was given a diagnosis of stage III melanoma. The patient underwent neck and back radiation and high-dose treatment with alpha interferon, followed by high-dose interleukin-2 and chemotherapy. Nevertheless, the patient died.

PLAINTIFF’S CLAIM The dermatologist’s office had no system to contact the patient when he didn’t return. The chances for cure would have been between 73% and 94% if the melanoma had been diagnosed at the time of the original excision.

THE DEFENSE No information about the defense is available.

VERDICT $1.7 million Massachusetts settlement.

COMMENT Failure to follow up on abnormal results is a potentially preventable cause of malpractice. Do you have a mechanism to track such testing?

Suggestive symptoms, but no Dx until it was too late

A 42-YEAR-OLD WOMAN went to the hospital in February for chest pain, dizziness, and shortness of breath. The emergency room physician diagnosed sinusitis and bronchitis and discharged the patient in stable condition. In April, the woman visited her primary care physician complaining of fatigue and shortness of breath. She claimed that her physician knew about the February emergency room visit. Later in April, she again went to her physician with shortness of breath; in July, she reported an irregular heart rhythm.

In October, the patient was found unresponsive after suffering cardiorespiratory arrest, hypoxic ischemic brain injury, and static encephalopathy. She has since been in a vegetative state.

PLAINTIFF’S CLAIM The patient had gone to her primary care physician many times during the 2 years before her emergency room visit with complaints suggesting an underlying cardiac condition, including shortness of breath, dizziness, light-headedness, vertigo, chest tightness, fatigue, and an irregular heart rhythm. The defendants were negligent in failing to diagnose the patient’s condition and provide proper treatment, failing to order proper diagnostic testing, and failing to perform a cardiac workup.

THE DEFENSE No negligence occurred.

VERDICT $6.3 million Florida verdict.

COMMENT Comprehensive documentation, including your medical decision making, can help prevent multimillion dollar judgments.

A serendipitous finding—to no avail

A FALL ON THE ICE sent a 74-year-old woman to the hospital with a fractured ankle. A preoperative chest radiograph taken before open reduction and internal fixation to repair the fracture showed a 2-cm nodular opacity in the right upper hemithorax. The radiologist recommended a computed tomography scan to rule out lung cancer, but the treating internists didn’t order a scan or refer the patient for biopsy.

The nodule appeared again on a second radiograph taken 2 days later. The patient wasn’t informed, and the attending internist at the time didn’t order follow-up testing or refer the patient to a specialist. The attending physicians continued to treat the patient without further testing or referral for the nodule.

Two years after the fracture, the patient was admitted to the hospital with complaints of sweating and shortness of breath. A chest radiograph showed pneumonia and the previously noted nodule. The patient was diagnosed with metastatic, inoperable small-cell lung cancer. She died after receiving extensive chemotherapy and radiation.

PLAINTIFF’S CLAIM The doctors were negligent in failing to diagnose and treat the lung cancer in a timely manner.

THE DEFENSE No information about the defense is available.

VERDICT $325,000 Michigan settlement.

COMMENT Could this happen to you? How many times have you serendipitously noted an abnormal result that was not followed up adequately?

Birth control prescription blamed for stroke

A 29-YEAR-OLD WOMAN SUFFERED A BLOOD CLOT in her leg. Her family physician advised her to start taking aspirin, which she did, and counseled her to use birth control that didn’t contain estrogen. She was taking norgestimate/ ethinyl estradiol at the time of the clot.

The woman subsequently went to an obstetrician-gynecologist (ob-gyn), whom she said she told about her family physician’s advice to avoid estrogen-containing birth control medication. The ob-gyn prescribed and inserted an etonogestrel/ethinyl estradiol vaginal ring.

A few months later the patient was hospitalized with severe headaches. She had blood clots in her brain and had suffered a stroke, which affected her speech and executive functions.

PLAINTIFF’S CLAIM The ob-gyn was negligent in prescribing the vaginal ring.

THE DEFENSE The cause of the first clot was an injury; the vaginal ring didn’t cause the second clot and stroke.

VERDICT $523,000 Georgia verdict.

COMMENT A comprehensive history, and clear documentation of communicating the potential risks of therapy, might have prevented this judgment.

Elevated PSA without referral delays diagnosis

ROUTINE BLOOD WORK before orthopedic surgery revealed an elevated prostate-specific antigen (PSA) of 7.4 in a 53-year-old man. A medical assistant who was directed to refer the patient to a urologist didn’t do so. Widespread metastatic prostate cancer was diagnosed 18 months later.

PLAINTIFF’S CLAIM Diagnosing the cancer 18 months earlier would have given the patient a >50% chance of 5-year survival. Because of the delay, he was terminal. The clinic was negligent in having no written procedure or system for tracking adverse lab test results.

THE DEFENSE The patient already had metastatic disease when the PSA level was discovered and would have required the same treatment.

VERDICT $1 million Washington settlement.

COMMENT A clear system for tracking test results is imperative in today’s litigious society.

Removal of mole without follow-up leads to death

A MOLE ON THE UPPER BACK prompted a 26-year-old man to visit a dermatologist, who performed a complete excision. The pathologist who examined the excised tissue suggested that the patient return for follow-up. During the next 6 months, the patient saw the dermatologist twice but didn’t receive proper follow-up.

Two years later, the patient noticed a suspicious area on his back near the scar from the excision. A hospital biopsy resulted in a diagnosis of metastatic melanoma. A review of the slides from the original biopsy found “melanoma, superficial spreading type, invasive to a depth of a minimum of 1.0 mm anatomic level IV, extending to inked deep resection margin.”

The patient underwent a wide local excision and was given a diagnosis of stage III melanoma. The patient underwent neck and back radiation and high-dose treatment with alpha interferon, followed by high-dose interleukin-2 and chemotherapy. Nevertheless, the patient died.

PLAINTIFF’S CLAIM The dermatologist’s office had no system to contact the patient when he didn’t return. The chances for cure would have been between 73% and 94% if the melanoma had been diagnosed at the time of the original excision.

THE DEFENSE No information about the defense is available.

VERDICT $1.7 million Massachusetts settlement.

COMMENT Failure to follow up on abnormal results is a potentially preventable cause of malpractice. Do you have a mechanism to track such testing?

Suggestive symptoms, but no Dx until it was too late

A 42-YEAR-OLD WOMAN went to the hospital in February for chest pain, dizziness, and shortness of breath. The emergency room physician diagnosed sinusitis and bronchitis and discharged the patient in stable condition. In April, the woman visited her primary care physician complaining of fatigue and shortness of breath. She claimed that her physician knew about the February emergency room visit. Later in April, she again went to her physician with shortness of breath; in July, she reported an irregular heart rhythm.

In October, the patient was found unresponsive after suffering cardiorespiratory arrest, hypoxic ischemic brain injury, and static encephalopathy. She has since been in a vegetative state.

PLAINTIFF’S CLAIM The patient had gone to her primary care physician many times during the 2 years before her emergency room visit with complaints suggesting an underlying cardiac condition, including shortness of breath, dizziness, light-headedness, vertigo, chest tightness, fatigue, and an irregular heart rhythm. The defendants were negligent in failing to diagnose the patient’s condition and provide proper treatment, failing to order proper diagnostic testing, and failing to perform a cardiac workup.

THE DEFENSE No negligence occurred.

VERDICT $6.3 million Florida verdict.

COMMENT Comprehensive documentation, including your medical decision making, can help prevent multimillion dollar judgments.

A serendipitous finding—to no avail

A FALL ON THE ICE sent a 74-year-old woman to the hospital with a fractured ankle. A preoperative chest radiograph taken before open reduction and internal fixation to repair the fracture showed a 2-cm nodular opacity in the right upper hemithorax. The radiologist recommended a computed tomography scan to rule out lung cancer, but the treating internists didn’t order a scan or refer the patient for biopsy.

The nodule appeared again on a second radiograph taken 2 days later. The patient wasn’t informed, and the attending internist at the time didn’t order follow-up testing or refer the patient to a specialist. The attending physicians continued to treat the patient without further testing or referral for the nodule.

Two years after the fracture, the patient was admitted to the hospital with complaints of sweating and shortness of breath. A chest radiograph showed pneumonia and the previously noted nodule. The patient was diagnosed with metastatic, inoperable small-cell lung cancer. She died after receiving extensive chemotherapy and radiation.

PLAINTIFF’S CLAIM The doctors were negligent in failing to diagnose and treat the lung cancer in a timely manner.

THE DEFENSE No information about the defense is available.

VERDICT $325,000 Michigan settlement.

COMMENT Could this happen to you? How many times have you serendipitously noted an abnormal result that was not followed up adequately?

Excessive opioids blamed for respiratory arrest

A MIDNIGHT VISIT TO THE HOSPITAL prompted by abdominal pain, nausea, and vomiting led to a diagnosis of acute pancreatitis and secondary conditions in a 67-year-old woman. She was admitted to the intensive care unit (ICU) and given pain medication, including Demerol, morphine, and a fentanyl transdermal patch, despite the fact that she was opioid naïve, with no tolerance to strong opioid-based medications. A black box warning for fentanyl specifies that it should not be administered to opioid-naïve patients for acute or short-term pain.

During her stay in the ICU, the patient received increasing amounts of pain medication. On the third day, a physician prescribed almost 10 times the dose given on the previous day. The patient subsequently suffered respiratory arrest, resulting in brain damage that left her with no short-term memory and in need of full-time care.

PLAINTIFF’S CLAIM Excessive administration of opioids caused respiratory arrest and brain damage.

THE DEFENSE Respiratory arrest resulted from the patient’s underlying illnesses, not opioid overdose. The patient did not show typical signs of overdose, such as slowed heart rate and decreased breathing, and was, in fact, agitated up to the time she went into respiratory arrest.

VERDICT Confidential Missouri settlement.

COMMENT I’m seeing many malpractice suits involving the prescription of opioids. Caution and due diligence are essential.

A rising PSA, but no evaluation

A 59-YEAR-OLD MAN received a prostate-specific antigen (PSA) score of 2.0 in 2003. In 2006, his score was 5.26. His primary care physician didn’t evaluate him for prostate cancer.

A year later, the patient complained of frequent, slow urination. A digital rectal examination revealed a hardened, nodular prostate. The patient’s PSA was 209. A biopsy showed stage 4 terminal prostate cancer. Computed tomography and bone scans of the abdomen and pelvis indicated metastasis to lymph nodes and bones. The patient wasn’t a candidate for surgery or radiation.

PLAINTIFF’S CLAIM The patient had been diagnosed with benign prostatic hypertrophy in 2005 and 2006, but had received no further evaluation. A biopsy should have been performed in 2003, at the time of the initial PSA test. If the cancer had been diagnosed and treated with radiation then, the patient’s condition wouldn’t have become terminal.

THE DEFENSE No information about the defense is available.

VERDICT $500,000 California settlement.

COMMENT We may disagree with the assessment that more aggressive evaluation would have been lifesaving. Nonetheless, the lack of follow-up and discussion with the patient makes for a very unfortunate situation.

A hemorrhoid…or something else?

WHILE GIVING BIRTH TO HER SECOND CHILD, a 35-year-old woman sustained a second-degree vaginal tear that required repair. The physician who performed the repair noticed a large hemorrhoid and told a nurse midwife to have it evaluated with a possible gastroenterological consult to rule out a mass. The next day, another doctor and midwife examined the patient. They agreed with the patient to defer a gastroenterology consult and have the patient follow up with her primary care physician in a few weeks.

When the patient saw her primary care physician 3 weeks after delivery, her exam revealed no hemorrhoids; she was instructed to call back if the hemorrhoids recurred. The hemorrhoids didn’t recur, and the patient didn’t follow up with her primary care physician.

During the next 4 years, the patient received care from her gynecologist that didn’t include rectal examinations. Five years after delivery, the patient went to her primary care physician complaining of rectal bleeding with bowel movements. The physician found no external hemorrhoids but noted a rectal mass.

He referred the patient for a gastroenterology consult and biopsy, which revealed intramucosal adenocarcinoma. A computed tomography (CT) scan of the chest showed a nodule in the lower lobe of the right lung, which was suspected to be a metastasis. An abdominal CT scan and a positron-emission tomography scan indicated likely liver metastasis. A liver biopsy confi rmed adenocarcinoma.

The patient underwent chemotherapy and chemoradiation followed several months later by abdominal perineal resection, left lateral segmentectomy of the liver, cholecystectomy, and appendectomy. At the time of the settlement, she was doing well and receiving no cancer treatment.

PLAINTIFF’S CLAIM The primary care physician should have followed up on the rectal finding, which would have led to earlier diagnosis and treatment of the cancer.

THE DEFENSE The finding made at the time of the delivery was a simple hemorrhoid, which went away after delivery. The absence of symptoms for 4½ years indicated that the cancer couldn’t have been present at the time of delivery. The diagnosed cancer was in a different place than the original hemorrhoid.

VERDICT $1 million Massachusetts settlement.

COMMENT The folly of the failed hand off. One of the most common root causes of litigation is poor communication that results in a bad outcome. How many lives could be saved simply by phone calls between physicians?

Excessive opioids blamed for respiratory arrest

A MIDNIGHT VISIT TO THE HOSPITAL prompted by abdominal pain, nausea, and vomiting led to a diagnosis of acute pancreatitis and secondary conditions in a 67-year-old woman. She was admitted to the intensive care unit (ICU) and given pain medication, including Demerol, morphine, and a fentanyl transdermal patch, despite the fact that she was opioid naïve, with no tolerance to strong opioid-based medications. A black box warning for fentanyl specifies that it should not be administered to opioid-naïve patients for acute or short-term pain.

During her stay in the ICU, the patient received increasing amounts of pain medication. On the third day, a physician prescribed almost 10 times the dose given on the previous day. The patient subsequently suffered respiratory arrest, resulting in brain damage that left her with no short-term memory and in need of full-time care.

PLAINTIFF’S CLAIM Excessive administration of opioids caused respiratory arrest and brain damage.

THE DEFENSE Respiratory arrest resulted from the patient’s underlying illnesses, not opioid overdose. The patient did not show typical signs of overdose, such as slowed heart rate and decreased breathing, and was, in fact, agitated up to the time she went into respiratory arrest.

VERDICT Confidential Missouri settlement.

COMMENT I’m seeing many malpractice suits involving the prescription of opioids. Caution and due diligence are essential.

A rising PSA, but no evaluation

A 59-YEAR-OLD MAN received a prostate-specific antigen (PSA) score of 2.0 in 2003. In 2006, his score was 5.26. His primary care physician didn’t evaluate him for prostate cancer.

A year later, the patient complained of frequent, slow urination. A digital rectal examination revealed a hardened, nodular prostate. The patient’s PSA was 209. A biopsy showed stage 4 terminal prostate cancer. Computed tomography and bone scans of the abdomen and pelvis indicated metastasis to lymph nodes and bones. The patient wasn’t a candidate for surgery or radiation.

PLAINTIFF’S CLAIM The patient had been diagnosed with benign prostatic hypertrophy in 2005 and 2006, but had received no further evaluation. A biopsy should have been performed in 2003, at the time of the initial PSA test. If the cancer had been diagnosed and treated with radiation then, the patient’s condition wouldn’t have become terminal.

THE DEFENSE No information about the defense is available.

VERDICT $500,000 California settlement.

COMMENT We may disagree with the assessment that more aggressive evaluation would have been lifesaving. Nonetheless, the lack of follow-up and discussion with the patient makes for a very unfortunate situation.

A hemorrhoid…or something else?

WHILE GIVING BIRTH TO HER SECOND CHILD, a 35-year-old woman sustained a second-degree vaginal tear that required repair. The physician who performed the repair noticed a large hemorrhoid and told a nurse midwife to have it evaluated with a possible gastroenterological consult to rule out a mass. The next day, another doctor and midwife examined the patient. They agreed with the patient to defer a gastroenterology consult and have the patient follow up with her primary care physician in a few weeks.

When the patient saw her primary care physician 3 weeks after delivery, her exam revealed no hemorrhoids; she was instructed to call back if the hemorrhoids recurred. The hemorrhoids didn’t recur, and the patient didn’t follow up with her primary care physician.

During the next 4 years, the patient received care from her gynecologist that didn’t include rectal examinations. Five years after delivery, the patient went to her primary care physician complaining of rectal bleeding with bowel movements. The physician found no external hemorrhoids but noted a rectal mass.

He referred the patient for a gastroenterology consult and biopsy, which revealed intramucosal adenocarcinoma. A computed tomography (CT) scan of the chest showed a nodule in the lower lobe of the right lung, which was suspected to be a metastasis. An abdominal CT scan and a positron-emission tomography scan indicated likely liver metastasis. A liver biopsy confi rmed adenocarcinoma.

The patient underwent chemotherapy and chemoradiation followed several months later by abdominal perineal resection, left lateral segmentectomy of the liver, cholecystectomy, and appendectomy. At the time of the settlement, she was doing well and receiving no cancer treatment.

PLAINTIFF’S CLAIM The primary care physician should have followed up on the rectal finding, which would have led to earlier diagnosis and treatment of the cancer.

THE DEFENSE The finding made at the time of the delivery was a simple hemorrhoid, which went away after delivery. The absence of symptoms for 4½ years indicated that the cancer couldn’t have been present at the time of delivery. The diagnosed cancer was in a different place than the original hemorrhoid.

VERDICT $1 million Massachusetts settlement.

COMMENT The folly of the failed hand off. One of the most common root causes of litigation is poor communication that results in a bad outcome. How many lives could be saved simply by phone calls between physicians?

Excessive opioids blamed for respiratory arrest

A MIDNIGHT VISIT TO THE HOSPITAL prompted by abdominal pain, nausea, and vomiting led to a diagnosis of acute pancreatitis and secondary conditions in a 67-year-old woman. She was admitted to the intensive care unit (ICU) and given pain medication, including Demerol, morphine, and a fentanyl transdermal patch, despite the fact that she was opioid naïve, with no tolerance to strong opioid-based medications. A black box warning for fentanyl specifies that it should not be administered to opioid-naïve patients for acute or short-term pain.

During her stay in the ICU, the patient received increasing amounts of pain medication. On the third day, a physician prescribed almost 10 times the dose given on the previous day. The patient subsequently suffered respiratory arrest, resulting in brain damage that left her with no short-term memory and in need of full-time care.

PLAINTIFF’S CLAIM Excessive administration of opioids caused respiratory arrest and brain damage.

THE DEFENSE Respiratory arrest resulted from the patient’s underlying illnesses, not opioid overdose. The patient did not show typical signs of overdose, such as slowed heart rate and decreased breathing, and was, in fact, agitated up to the time she went into respiratory arrest.

VERDICT Confidential Missouri settlement.

COMMENT I’m seeing many malpractice suits involving the prescription of opioids. Caution and due diligence are essential.

A rising PSA, but no evaluation

A 59-YEAR-OLD MAN received a prostate-specific antigen (PSA) score of 2.0 in 2003. In 2006, his score was 5.26. His primary care physician didn’t evaluate him for prostate cancer.

A year later, the patient complained of frequent, slow urination. A digital rectal examination revealed a hardened, nodular prostate. The patient’s PSA was 209. A biopsy showed stage 4 terminal prostate cancer. Computed tomography and bone scans of the abdomen and pelvis indicated metastasis to lymph nodes and bones. The patient wasn’t a candidate for surgery or radiation.

PLAINTIFF’S CLAIM The patient had been diagnosed with benign prostatic hypertrophy in 2005 and 2006, but had received no further evaluation. A biopsy should have been performed in 2003, at the time of the initial PSA test. If the cancer had been diagnosed and treated with radiation then, the patient’s condition wouldn’t have become terminal.

THE DEFENSE No information about the defense is available.

VERDICT $500,000 California settlement.

COMMENT We may disagree with the assessment that more aggressive evaluation would have been lifesaving. Nonetheless, the lack of follow-up and discussion with the patient makes for a very unfortunate situation.

A hemorrhoid…or something else?

WHILE GIVING BIRTH TO HER SECOND CHILD, a 35-year-old woman sustained a second-degree vaginal tear that required repair. The physician who performed the repair noticed a large hemorrhoid and told a nurse midwife to have it evaluated with a possible gastroenterological consult to rule out a mass. The next day, another doctor and midwife examined the patient. They agreed with the patient to defer a gastroenterology consult and have the patient follow up with her primary care physician in a few weeks.

When the patient saw her primary care physician 3 weeks after delivery, her exam revealed no hemorrhoids; she was instructed to call back if the hemorrhoids recurred. The hemorrhoids didn’t recur, and the patient didn’t follow up with her primary care physician.

During the next 4 years, the patient received care from her gynecologist that didn’t include rectal examinations. Five years after delivery, the patient went to her primary care physician complaining of rectal bleeding with bowel movements. The physician found no external hemorrhoids but noted a rectal mass.

He referred the patient for a gastroenterology consult and biopsy, which revealed intramucosal adenocarcinoma. A computed tomography (CT) scan of the chest showed a nodule in the lower lobe of the right lung, which was suspected to be a metastasis. An abdominal CT scan and a positron-emission tomography scan indicated likely liver metastasis. A liver biopsy confi rmed adenocarcinoma.

The patient underwent chemotherapy and chemoradiation followed several months later by abdominal perineal resection, left lateral segmentectomy of the liver, cholecystectomy, and appendectomy. At the time of the settlement, she was doing well and receiving no cancer treatment.

PLAINTIFF’S CLAIM The primary care physician should have followed up on the rectal finding, which would have led to earlier diagnosis and treatment of the cancer.

THE DEFENSE The finding made at the time of the delivery was a simple hemorrhoid, which went away after delivery. The absence of symptoms for 4½ years indicated that the cancer couldn’t have been present at the time of delivery. The diagnosed cancer was in a different place than the original hemorrhoid.

VERDICT $1 million Massachusetts settlement.

COMMENT The folly of the failed hand off. One of the most common root causes of litigation is poor communication that results in a bad outcome. How many lives could be saved simply by phone calls between physicians?