By Marilys Fernandez, RN, JD

[Digest, Spring, 1991]

Allegation

Insured ophthalmologist failed to review a preoperative chest x-ray which was ultimately shown to be suggestive of carcinoma of the lung.

Disposition

Settled during trial.

Background

It is customary practice for ophthalmologists to routinely review results obtained from A-scans, visual field tests, fluorescein angiograms and a variety of other diagnostic tools prior to ophthalmic surgery. However, practices in reviewing chest x-rays and lab work routinely ordered preoperatively for patients undergoing surgery can vary considerably.

In a recent review of OMIC claims, reviewers identified a number of cases based on the ophthalmologist's failure to review non-ophthalmological diagnostic studies. The resulting cases related to claims of missed diagnosis and delay in treatment, often of ailments unrelated to eye disease. The largest payment to date made on behalf of an OMIC insured was over $250,000 for injuries resulting from failure to review a preoperative chest x-ray which was ultimately shown to be suggestive of carcinoma of the lung.

Case Summary

The patient was a 60-year-old male who over the years developed age-related cataracts reducing his vision in both eyes. Cataract surgery was performed on the left eye with good results. Preoperatively, a chest x-ray was ordered by the ophthalmologist to comply with the hospital's policy that such tests be performed on all surgical candidates over 40 years of age. The x-ray was interpreted by the radiologist as abnormal but was never reviewed by the ophthalmologist prior to surgery.

Four months later, the patient elected to have cataract surgery on his right eye. Another preoperative chest x-ray was performed which showed an enlargening left hilum with a lobulated mass present. The ophthalmologist was informed of the abnormal finding after the patient had been inducted but proceeded with the surgery anyway.

The chest x-ray taken prior to the first cataract surgery was then reviewed and found to indicate the presence of a nodular density in the left hilum. A later CT scan appeared to confirm that the mass had grown significantly in those four months. Following a left thoracotomy and pneumonectomy, the mass was found to be a poorly differentiated adenocarcinoma with four of eight hilar lymph nodes positive for metastatic cancer.

According to a pulmonary oncologist who reviewed the case, the first chest x-ray showed no metastasis to the nodes. Had the patient been treated at that time, he arguably might have had a 50 to 55 percent chance for a 5-year survival rate. With the four-month delay in diagnosis and treatment, the chances for a 5-year survival might have dropped to between 15 and 25 percent.

Outcome

Although there was potential exposure on the part of the hospital, anesthesiologist and radiologist for not being more aggressive in bringing to the attention of the ophthalmologist the results of the first chest x-ray, it remains the attending physician-surgeon's responsibility to follow up on all tests ordered and to review the results of all preoperative tests.

After OMIC assessed the liability exposure of the case, the claims management staff entered into settlement negotiations with the plaintiff's attorney and settled the claim with consent of the insured ophthalmologist.

The co-defendants involved, namely, the hospital, anesthesiologist and radiologist, refused to participate in settlement and were later sued by the patient. The outcome of that suit has yet to be determined.

Risk Management Principles and Commentary

This case presents a number of fundamental principles that ophthalmologists can follow to help avoid or reduce diagnosis-related claims. In particular, systems should be developed in the ophthalmic office to assure the efficient processing of all diagnostic clinical information.

Such systems could include:

• A method for ensuring that laboratory results, consultation reports and other pertinent documents are seen by the treating/attending physician before such information is filed.
• A reminder or diary system which ensures that follow-up tasks, such as notifying patients of test results, are undertaken when warranted.
• A formal arrangement whereby test results that are adverse or require immediate attention be reported personally by the consulting physician to the physician who requested them.

Additional suggestions may be found in the publication Risk Management Principles and Commentaries for the Medical Office published by the AMA/Specialty Society Medical Liability Project.