Unraveling Diagnostic Error: Delving Deeply to Identify Hidden Human Factors

Case study 2: Missed diagnosis on x-ray

Radiologist A, when reviewing a chest x-ray of a 65-year-old woman with chest pain, dyspnea, and cough of three months’ duration, found a left-sided pulmonary mass and pleural effusion, most consistent with advanced, regionally metastatic carcinoma. A review of an earlier film, obtained about one year beforehand, revealed a somewhat faint, small mass in the left mid-lung field adjacent to, but distinct from, the pulmonary hilum.

Radiologist A showed the earlier film to several colleagues without prompting, and all of them identified the lesion. In fact, he placed this x-ray in a pile to be read without informing another colleague, and that colleague identified the lesion correctly. Though the mass was subtle, the radiologist’s colleagues who reviewed the earlier film felt the mass should have been apparent to Radiologist B, who had officially interpreted the film a year earlier.

Further evaluation of this patient, including chest CT scan and pleurocentesis, confirmed the diagnosis, and extensive staging revealed both hepatic and cerebral lesions: stage 4 metastatic disease. The patient succumbed six months later, leaving behind her husband of 40 years. She missed the birth of her first grandchild.

The identification of the earlier chest x-ray findings triggered a root cause analysis, which concluded that Radiologist B, one year earlier, had missed the “obvious” finding, resulting in the delay in diagnosis and possibly contributing to the patient’s demise, or at least to a shortening of her life expectancy. Radiologists A and B and the hospital were sued, and Radiologist B attempted suicide with an overdose of narcotics and antidepressants. Fortunately, he survived.

A secondary investigation was undertaken to evaluate the performance of Radiologist B, and this investigation identified several hidden factors, not uncovered in the original investigation, that collectively contributed to causality. Radiologist B’s marriage had been failing for some time, and his wife had been having an extramarital affair with a close friend. Radiologist B had been seeing a psychiatrist for his anxiety and depression; he was medicated and drank heavily. Clearly he was an impaired provider. His social problems were well known by colleagues, but his department chair was unaware of his difficulties, in part because the two of them had a contentious relationship and Radiologist B had not broached the subject. None of his colleagues had brought the radiologist’s issues to the chair’s attention or provided any meaningful personal assistance.