Washington – Hospitalist – CT Scan Results Reveal A 3.3 cm Right Renal Mass Mentioned On Page Two Of The Report

On 8/2/2014, a patient presented to the hospital for shortness of breath.  A hospitalist assumed care of the patient and admitted him for inpatient treatment.  Based on the patient’s presentation, the hospitalist ordered multiple labs and radiology studies, including a chest computed tomography scan (CT) with contrast, to rule out serious lung conditions, such as pulmonary embolism.  The 8/2/2014 chest CT report was negative for pulmonary embolism, but did show a 3.3 cm right renal mass highly suggestive of malignancy.  No mention of the renal mass was noted in the hospitalist’s chart notes.  The hospitalist reviewed page one of the CT report which was negative for pulmonary embolism, eliminating the problem from the hospitalist’s differential diagnosis.  The right renal mass suggestive of malignancy was reported on page two of the report; however, the hospitalist was not aware there was a page two.

The hospitalist indicated in her statement to the Commission that she did review the CT report and focused on the findings that addressed the current lung complaints.  She indicated that because the patient did not have complaints suggestive of a renal or bladder issue, she did not order the CT to evaluate renal issues.

The hospitalist continued to follow the patient throughout the hospital admission and prepared the discharge summary.  On 8/6/2014, she discharged the patient.  The discharge diagnoses included bilateral pneumonia, sepsis, and exacerbation of chronic obstructive pulmonary disease (COPD).  The discharge summary recommended that the patient follow up with his primary care provider in one week.  No recommendations were documented regarding the renal mass.

On 8/25/2014, the patient followed up with his primary care provider.  Notes do not indicate that the primary care provider was notified of the renal mass.  The patient continued to follow up with multiple providers for various medical conditions between August 2014 and March 2015.  The patient indicated that on follow-up for psoriasis with a different provider, the renal mass was brought to his attention.  On 3/31/2015, the patient underwent a follow-up CT, which showed that the renal mass had increased in size.  Subsequently, the patient was confirmed to have renal carcinoma and underwent successful treatment.

The Commission stipulated the hospitalist reimburse costs to the Commission, develop and follow a written protocol for the clinic to ensure outside lab and other tests results are promptly reviewed, and write and submit a paper of at least 1000 words, plus bibliography, addressing the standard of care applicable to the ordering provider when reviewing lab/radiology reports and the ordering provider’s responsibility for arranging follow-up of abnormal results.

State: Washington


Date: September 2016


Specialty: Hospitalist, Emergency Medicine, Family Medicine, Internal Medicine, Oncology


Symptom: Shortness of Breath


Diagnosis: Cancer, Pneumonia, Sepsis


Medical Error: Failure to follow up, Diagnostic error


Significant Outcome: N/A


Case Rating: 4


Link to Original Case File: Download PDF



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