Did PSA finding get lost in the shuffle?
A SCREENING PROSTATE-SPECIFIC ANTIGEN (PSA) TEST ordered for a 76-year-old man by his primary care physician was within normal limits at 3.1. Two years later, the patient saw a urologist, who diagnosed renal cysts and bladder trabeculation based on a CT scan. Five months after that, the primary care physician ordered a second screening PSA, which was elevated at 12.
About a week later, the primary care physician noted that the patient was scheduled to see the urologist the next day, but didn’t indicate that the urologist had been informed of the elevated PSA or that the patient had been told of its significance. A letter from the primary care physician to the urologist after the patient’s visit stated that the patient was being treated for microscopic hematuria but didn’t mention elevated PSA. A letter several weeks later from the urologist to the primary care physician discussed the patient’s elevated PSA. The primary care physician didn’t contact the urologist to follow up on the finding, however.
After a year of testing, the urologist concluded that the hematuria was probably related to the kidney, or perhaps the prostate, and started the patient on dutasteride, which helped the bleeding. Two months after the start of treatment, the urologist ordered a PSA test, which was extremely elevated. A subsequent biopsy revealed adenocarcinoma, and a bone scan showed metastatic bony disease, which hadn’t shown up on a bone scan done 6 months before. The patient died 2 years later. The cause of death was listed as cardiopulmonary arrest, cardiogenic shock, and myocardial infarction.
PLAINTIFF’S CLAIM The plaintiff’s claim focused on the handling of the PSA test, though the specifics of the claim were not detailed in the case summary.
DOCTOR’S DEFENSE The primary care physician claimed that his nurse told the patient after the second PSA test that the PSA was 12 and encouraged the patient to see the urologist to discuss the elevated level. The physician also claimed that he had faxed the elevated PSA test result to the urologist and that the patient was reminded of the elevated PSA during his visit to the urologist. No information about the urologist’s defense was available.
VERDICT $325,000 Massachusetts settlement.
COMMENT Coordination of care and documentation of communication are keys to good patient care—and avoiding lawsuits.
Woman sent home from ER dies of aneurysm
SEVERE HEADACHES prompted a 38-year-old woman to visit her family physician, who referred her to a neurologist; an appointment was scheduled for more than a month later. A month after seeing the family physician, the patient went to the emergency room complaining of a severe headache.
A CT scan ordered by the ER physician showed a large mass in the patient’s brain. The ER physician gave the patient the scan report, told her to see her family doctor, and sent her home without consulting a neurosurgeon. Later that day, the aneurysm ruptured; the patient’s family took her to the hospital, where she died the next morning.
PLAINTIFF’S CLAIM The family physician should have ordered a CT scan, which would have revealed the aneurysm. The ER physician should have ordered an immediate neurologic consult, which would have led to surgical repair of the leaking aneurysm. Either measure would have saved the patient’s life.
DOCTOR’S DEFENSE The family physician claimed that the patient’s complaints weren’t urgent and he made a proper referral. The ER physician claimed that the patient wouldn’t have lived even if he’d arranged an immediate consult.
VERDICT $1.5 million Michigan verdict against the ER physician.
COMMENT This case illustrates the value of clearly documenting referrals and suggesting follow-up if a change in symptoms occurs.