On 10/05/2012, a 65-year-old man presented to the emergency department with “pain, sprain, right leg numbness, and thigh burning” The radiologist’s report documented degenerative changes of the lumbar spine, right hip, and right knee.
On 04/22/2014, the patient was found unresponsive with apnea, asystole, and a Glasgow coma score of 3. Emergency medical technicians administered cardiopulmonary resuscitation and transported him to an emergency department
A CT scan showed a ruptured large fusiform abdominal aortic aneurysm of the mid- to distal abdominal aorta/aortic bifurcation and a large associated retroperitoneal hematoma. The patient was transferred to another hospital where he died later that day.
The Board’s consultant reviewed the radiograph taken on 10/05/2012 and noted that the image clearly shows an abdominal aortic aneurysm with calcified AP diameter of 9.6 cm on the coned-down view of the lumbosacral junction. The consultant noted that on the full lateral view, which is collimated, only the calcified posterior wall of the abdominal aorta is visualized.
The Board judged the radiologist’s conduct to be below the minimum standard of competence given failure to identify and report the abdominal aortic aneurysm on the lumbar spine x-ray.
The Board ordered the radiologist to be reprimanded.
Date: June 2016
Medical Error: False negative
Significant Outcome: Death
Case Rating: 4
Link to Original Case File: Download PDF
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