radiology errors lead to 11 weeks in coma for pennsylvania woman

The technology that is available to assist with medical treatments is amazing. For example, teleradiology enables doctors to send digital copies of X-rays, CT scans and mammograms to radiologists that have the specialization to identify problems.

Because many hospitals do not have the budget to keep radiologists on staff 24/7, teleradiology allows doctors to provide their patients with prompt test results at all hours of the day. However, the technology can also create an opportunity for the type of miscommunication that can put patients’ health at risk.

Recently, a 30-year-old woman from Pennsylvania spent 11 weeks in a coma because of a radiology error caused by teleradiology.

With teleradiology, critical information is conveyed digitally, so the doctor who takes the scans may not actually talk to the radiologist who is analyzing them. In addition, scans may be sent through several channels before they finally make it back to the patient. This may create a situation in which each doctor notes observations or concerns, but by assuming another doctor will prepare the final report, no one takes the time to thoroughly review and interpret those observations.

Jennifer, the 30-year-old from Pennsylvania, went to the emergency room complaining of a headache. The doctor suspected a cerebral hemorrhage, which can be fatal, and ordered a CT scan of her brain.

Because it was 6:00 p.m. on a Friday night, there was not a radiologist on site. The scans were sent to another hospital in Pennsylvania. The doctor said Jennifer did not have a hemorrhage, but he thought she might have a tumor. While the prognosis was frightening, it was not immediately life-threatening.

Jennifer scheduled a follow-up appointment, received painkillers and went home. Within 12 hours, she was in so much pain that she called an ambulance and was rushed back to the hospital. The doctor ordered a more detailed scan.

The scans were sent to the hospital’s contract company; the contract company sent them to a subcontracting company, and the subcontracting company sent them to one of its radiologists — who was working from his home in Hong Kong. The radiologist noted a buildup of fluid around the woman’s brain, but he did not include any information about what it could mean, nor did he say it is almost always fatal if it is left untreated.

Apparently, everyone involved assumed someone else was connecting the dots. The woman was again discharged from the ER. The next day her parents found her unconscious on the floor. The fluid surrounding her brain had ruptured. She spent 11 weeks in a coma.

In this case, as in so many others, a breakdown in communication put a patient’s life at risk. How many lives need to be lost or forever altered before some health care professionals and medical facilities understand that clear communication is essential to protect patients from harm?

Read our upcoming blog posts to learn more about the ramifications of the doctors’ errors in this case, as well as similar errors that have occurred at other hospitals.

Source: msnbc, “Is a doctor reading your X-rays? Maybe not,” Katherine Eban, SELF, Oct. 26, 2011

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