Risk Management



Failure to Diagnose a Brain Lesion in a Referred Patient

 Digest, Fall, 1992

 

ALLEGATION  Insured ophthalmologist allegedly failed to diagnose an occipital brain lesion.

DISPOSITION  Motion of Summary Judgment was granted.

 

Background

In malpractice cases where defense counsel believes there are no issues of material fact for a jury to decide, counsel can request that the matter be dismissed prior to trial by filing a Motion for Summary Judgment. A Summary Judgment allows a judge to make an independent ruling on the legal issues in the case. Scrupulous medical records are essential for such motions to prevail.

 

Case Summary

The patient was a 60-year-old female who initially presented to the emergency department with complaints of dizziness, headaches and blurred vision of several days duration. She was admitted to the hospital for a diagnostic workup to include a CT scan which was reported as normal. She was diagnosed with transient ischemic attack with carotid atherosclerosis and was ultimately discharged.

The family practitioner referred the patient for follow-up to a neurologist, psychiatrist and the insured ophthalmologist. No neuro deficits were found. Initially, the insured treated the patient for wide-angle glaucoma. On a subsequent visit, the insured did a visual field examination which revealed a right homonymous hemianopsia. The insured discussed these findings with the family physician who reviewed the CT scan. A repeat CT scan was not performed at that time.

Three months later, the patient was admitted again as an inpatient for a diagnostic workup. A subsequent CT scan revealed an area of infarct. An alternate diagnosis of tumor was considered, but ruled out given the distribution and involvement of the cortex. Based on this and a cerebral angiogram, the patient was diagnosed with ischemic infarction secondary to ASHD. She was seen then by another ophthalmologist for treatment of her original complaints as presented to the insured. Two months later, the patient was diagnosed with inoperable mass of the occipital area. Suit was filed against all treating physicians.

 

Outcome

After initial pleadings and discovery, a Motion for Summary Judgment was granted based on the testimony of independent expert physicians who supported the insured’s position. They concluded that the lesion was a non-treatable condition at the time the plaintiff presented to the insured and that the plaintiff’s presenting symptoms were appropriately treated. The insured’s patient records indicated appropriate referral and follow-up with the family practitioner and, as such, adherence to the standard of care. The record keeping of the insured thus became an essential part of the defense and summary judgment for the defendant.

 

Risk Management Principles and Commentary

Ophthalmologists are often referred patients by another treating physician. As a means of loss control, measures should be instituted to provide for coordination of care. In this day and age of managed care, this is not always possible. However, follow-up and documentation often are key measures in the prevention of losses. The following may assist in this process:

  • Obtain a complete medical history from the patient and referring physician.
  • Maintain communication with the referring physician. This includes copies of all diagnostic reports and consults of other treating physicians as well as the ophthalmologist’s own conclusions.
  • Promptly make referrals to and follow-up with subspecialists when there are suspicions of an unconfirmed diagnosis.
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