At the 2015 Diagnostic Error in Medicine International Conference, a panel of experts made it clear in a discussion that there are many subtleties in mitigating liability for diagnostic errors in clinical practice. It can be a difficult balancing act between performing a good differential diagnosis and merely conducting defensive medicine, between hitting and missing the sometimes tiny window of opportunity for making the right diagnosis and starting the appropriate intervention, and in determining which errors are truly actionable and which are not, the panelists noted.
“Depending on the disease state, it can be much more complicated than simply saying there is a diagnostic error, because someone did not come to the right diagnosis,” panelist Mary-Elizabeth Knox, Vice President, Claims, Medical Mutual Insurance Company of Maine, Portland, told Oncology Practice Management. “Nobody is going to come to you, particularly in the emergency department, with a handy tag saying, ‘I have viral meningitis,’ because not everyone exhibits the classic signs and symptoms.”
The discussion centered on 2 cases, one of which was handled by the office of Ms Knox. Although neither case deals with cancer, they are nonetheless directly related to oncology and every other field of medicine, noted Hayes V. Whiteside, MD, Chief Medical Officer and Senior Vice President of Risk Resource, ProAssurance Corporation, Birmingham, AL. ProAssurance sells malpractice insurance to physicians and other professionals.
The first case involved a boy aged 6 years who developed headaches, nausea and vomiting, and other serious symptoms, and he began tilting his head to one side. The child was diagnosed with headache and hypertension but was never thought to have a more serious condition, because a noncontrast computed tomography did not find anything unusual. After his death, an autopsy revealed a transtentorial herniation that resulted from cerebral edema caused by a right cerebellum medulloblastoma.
The second case was a Physician Insurers Association of America claim and involved an aortic dissection with an atypical presentation. The patient was a man aged 67 years who had previously been diagnosed with acute renal failure, hypertension, prostate cancer, a nonfunctioning right kidney, and bipolar disorder who presented to the emergency department with several symptoms, including dyspnea, orthopnea, and nausea and vomiting. A chest x-ray showed aneurysmal dilation of the thoracic aorta, and the emergency department physician diagnosed the man with acute renal failure and admitted him to the hospital.
The next day, the patient developed respiratory distress, had a heart attack, and became unresponsive with no blood pressure while being transferred to the critical care unit. An autopsy revealed a dissected aortic aneurysm. The case was settled for $400,000 because the diagnosis of a dissected aortic aneurysm was not considered in the workup, even though several signs and symptoms pointed to this condition.
“A lot of doctors will look at these case studies and, unless they are specifically in their field, they feel they don’t apply to them,” said Dr Whiteside. “And so we show them that our main points don’t have to do with the specifics of these cases, but rather that you have to go through certain steps to be able to work through these problems, such as following up on an x-ray or a laboratory finding, and that they’re applicable to every branch of medicine.”