Missed Lung Nodule Results in Fatal Diagnosis

• Clear processes for provider-provider communication are essential.

• Closing the loop on abnormal test results and referrals is necessary to ensure the patient receives appropriate follow-up care. 

Description

A one-year delay in diagnosing a melanoma lung lesion resulted in patient’s death. 

Clinical sequence

A 40-year-old presented to a clinic after a motor vehicle accident. A chest X-ray showed fractured ribs and clear lungs. Two months later, the patient returned due to ongoing left upper chest pain and was examined by a nurse practitioner (NP) who noted that the patient was experiencing ongoing rib pain and ordered a chest CT. 

The radiologist identified an 8 mm nodule in the patient’s right lower lung and recommended a repeat CT in 3 months, a biopsy, and a possible PET scan. The NP was notified and reexamined the patient a couple of days later. During this exam, the NP focused on a possible thoracic spine compression fracture and did not document or acknowledge the presence of the lung nodule. The NP ordered an MRI of the thoracic spine. The radiologist, again, mentioned the lung nodule in their report. 

Seven months later, the patient returned with new hip pain which the NP diagnosed and treated. Two weeks after that, the patient presented with new onset abdominal pain, and an abdominal CT was completed. 

The abdominal CT showed that the lung nodule had doubled in size and there was concern for malignancy. The radiologist recommended a chest CT with IV contrast. The patient was not notified of the findings and the NP did not follow up on the test or read the report. 

Six months later, the patient returned with chest and back pain and dyspnea. A chest X-ray showed that the lung nodule had now quadrupled in size. The radiologist notified the patient and the NP of the findings via telephone. 

Ultimately, the patient had melanoma metastasize to the lung, brain, spine, and abdominal organs. The patient died shortly after their diagnosis. 

Allegation

It was alleged that the delay in diagnosing the patient’s lung nodule contributed to their death. 

Disposition

The case was settled in the medium range. 

Clinical Analysis

The clinical factors that contributed to this case included:

Narrow diagnosis focus

• Although the patient returned multiple times with symptoms, the NP did not consider or acknowledge the lung nodule as part of the differential diagnosis.

Inadequate patient assessment

• The NP only treated the present symptom for the current visit and did not complete a thorough assessment.

Failure to appreciate and reconcile relevant sign/symptom test result

• The NP did not follow up on first chest CT result that showed a lung nodule during the patient’s subsequent visits.

Inadequate communication among providers regarding findings in the medical record

• There were multiple opportunities for the NP to review the results and communicate with the radiologist. The radiologist mentioned the findings in their report but did not connect with the patient and NP until six months later when the lung nodule had quadrupled in size. 

This case demonstrated a lack of systematic patient follow-up for abnormal test results. Programs such as Ambulatory Safety Nets (ASNs) can help ensure closed-loop communication and proper documentation. These high-reliability, human-centered programs can assist with:

• Registries for patients with abnormal results/outstanding referrals

• Communication workflows

• Patient navigators

Discussion Questions

1. Do you have a process for following up on incidental findings from imaging?

2. What are your organization’s primary methods of provider-provider and provider-patient communications?