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For many years, when we would do our patient safety orientation to our incoming residents, we had one slide that said Never Assume It will make an Ass out of U and Me. We came across a recent sad story of how an assumption probably led to a premature death of a patient.
A woman in her 80s was hospitalized in Japan in December 2017 with a femur fracture and underwent a CT scan (Mainichi 2022). A doctor in the diagnostic radiology department noticed the suspicion of lung cancer and compiled an examination report. However, the attending orthopedic surgeon reportedly did not read the report because the woman's fracture surgery had already been completed. In December 2021, the woman was hospitalized again for a lumbar compression fracture. The same radiologist prepared a report acknowledging the suspicion of lung cancer, but mistakenly assumed that her cancer treatment had already begun and failed to alert her attending physician, a different orthopedic surgeon from 2017. The surgeon reportedly only looked at the CT of the lumbar spine and failed to check the report. In May 2022, the woman was again transported to a hospital for suspected heart failure. Because of fluid in her lungs, a respiratory physician checked the two previous reports and found the description of suspected lung cancer. However, it was too late and the patient died. The hospital director apologized, saying, "If she had started treatment earlier, she might have survived."
Such assumptions are a sure way to court similar disasters. In our numerous columns on communicating significant results to avoid patients falling through the cracks, we have emphasized the need for multiple people to have systems in place to ensure the message does not get lost. Every radiology department must have in place a system that ensures the message about the suspicious imaging finding was received by the ordering clinician (or clinician who will be providing ongoing care).
See also our other columns on communicating significant results:
Patient dies after info-sharing error at Japan hospital delays cancer diagnosis for 4.5 yrs. The Mainichi 2022; November 25, 2022
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