Malpractice Case: How Did Physicians Miss This Dangerous Abscess?

Jacqueline Ross, PhD, RN; David L. Feldman, MD, MBA


December 22, 2021

This case illustrates why physicians need to double- or triple-check test results before making a diagnosis.

An obese woman in her late forties came in to the emergency department (ED) over the weekend complaining of severe shoulder pain (10/10). The ED physician saw her and noted that her shoulder was warm to hot, but the patient had no fever.

Hospital staff attempted to aspirate fluid from the glenohumeral joint, and the subacromial bursa failed. The ED doctor ordered an MRI, which was done. However, before the results of the scan were returned, the ED physician diagnosed the patient with a rotator cuff injury, gave her information on the injury, and discharged her.

Later that day (this was a Sunday afternoon), the ED physician said he had spoken to the radiologist, who said the MRI on the patient was unremarkable. The ED physician did not review the MRI scan or report. The ED physician called the patient later that evening and told the patient the MRI was normal and to follow up with an orthopedic doctor in a few days.

A few hours later, the radiologist dictated her report as subcutaneous edema overlying the shoulder, suggesting cellulitis. The radiologist also noted a possible abscess at the acromioclavicular joint.

The following day the patient returned with low back pain and shoulder pain that had improved some. The same ED physician documented that the shoulder was swollen, warm, and red, but also noted that shoulder imaging from the day before had not shown anything. No other labs or imaging were ordered. No one read the MRI report from the prior evening. The diagnosis was a back spasm, and the patient was given a prescription for Flexeril (cyclobenzaprine).

The next morning, the patient was taken by ambulance to a different hospital. Her temperature was 104 °F. She was admitted to the ICU. Her diagnosis was sepsis and shoulder infection. She had surgery and remained in the hospital for 10 days, followed by a 6-week course of IV antibiotics at home through a PICC line. She has returned to her baseline health.

She sued the original ED physician and the hospital for failure to diagnose. The plaintiff attorneys did not call any experts.

The defense expert on the claim was mixed in the review of the claim. The expert noted that there was a clear miss on the correct diagnosis for the patient. The ED doctor did not review the report and communicate appropriately with the radiologist.

Still, the medical opinion was that this delayed diagnosis did not ultimately significantly affect the outcome for the patient. The patient did have an increase in pain and a delay in recovery. The case settled for a small amount.

How to Prevent Lawsuits Like the One Above: Dr Feldman's 3 Ps

  1. Prevent adverse events by using clinical judgment in recognizing signs and symptoms or ordering additional tests when you see possible signs of an infection. Additionally, read the patient's medical record; it's essential for patient safety, especially with a patient returning the next day for the same complaints. In this claim, if the ED physician had completed this step, he would have discovered that the MRI showed subcutaneous edema overlying the shoulder, suggesting cellulitis, as well as a possible abscess. The patient would have been admitted to the hospital sooner for IV antibiotics.

  2. Preclude malpractice claims by providing the patient with education on what symptoms to be alert for and when to call or return to the ED based on symptoms. Provide education that is easy to understand for patients. Developing rapport with patients is important but is particularly difficult for an ED physician. The fact that this ED physician contacted the patient at home after the ED visit is helpful, but unfortunately, he had incorrect information.

  3. Prevail in lawsuits by documenting your discussions with other providers, such as radiologists, regarding test results. Include the name of the provider and any other specifics related to the case. This is critical for ED physicians, who interact with physician consults on a routine basis.

This case comes from "Study of Emergency Department Diagnosis Case Type Malpractice Claims," published by The Doctors Company.


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