case study: miscommunication

In 1997, a 31 year old man underwent chest radiography prior to urologic surgery. The radiologist reported a possible lung tumor and recommended a CT scan. The radiologist's report was received by the transcriptionist but was sent to the wrong referring physician, who ignored it. The actual attending physician never received the report. Twenty one months later a follow up chest radiograph was performed only to reveal marked interval growth of a lung tumor. Shortly afterwards the patient died of lung carcinoma.

The patient's family filed a medical malpractice lawsuit, relying upon the testimony of an expert physician affidavit to find the radiologist at fault through error of proper communication. The lawsuit was eventually settled for $3.25 million dollars. Payment was equally apportioned to the three defendants; the hospital, the attending physician and the radiologist.