On 10/27/2015, a patient presented to the emergency department after suffering a fall.
An emergency department physician ordered a computerized tomography (CT) scan of the patient’s head.
Radiologist A reviewed the CT scan. Radiologist A failed to recognize or failed to report the presence of a significant subdural hematoma. Radiologist A erroneously reported that the CT scan showed no acute intracranial abnormalities.
The patient’s wounds from the fall were treated, and the patient was discharged home. That night, the patient became unresponsive at home and was transported back to the hospital.
A second CT scan was performed and was reviewed by Radiologist B. Radiologist B compared the second CT scan to the first CT scan performed earlier that day.
Radiologist B noted that the first CT scan showed a 6 mm hematoma. He reported that the second CT scan showed that the hematoma had markedly increased in size to 28 mm since the first scan taken approximately six hours before.
The patient expired the morning of 10/28/2015, due to complications from an acute subdural hematoma.
The Board judged Radiologist A’s conduct to be below the minimal standard of competence given that she failed to recognize and report any significant abnormalities present on a patient’s CT scan.
It was requested that the Board order one or more of the following penalties for Radiologist A: permanent revocation or suspension of her license, restriction of practice, imposition of an administrative fine, issuance of a reprimand, probation, corrective action, payment of fees, remedial education, and/or any other relief that the Board deemed appropriate.
Date: June 2017
Medical Error: False negative
Case Rating: 3
Link to Original Case File: Download PDF
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