Tag Archives: Misdiagnosis

Patient Rediagnosis Lifts Death Sentence

By ThinkReliability Staff

A patient diagnosed with stage-four lung cancer and given less than a year to live was relieved to have the correct diagnosis – treatable sarcoidosis. However, he was then concerned about how the misdiagnosis occurred in the first place, risking his health had he gone along with a recommendation for chemotherapy.

After nearly a year of coughing, the patient underwent a CT scan and was diagnosed with sarcoidosis, a treatable lung disease. Shortly after that diagnosis, a lung biopsy found the presence of stage-four lung cancer. The patient was referred to an oncologist, who recommended chemotherapy. Luckily for the patient, the diagnosis didn’t seem right and he sought a second opinion. Although the tissue samples from the initial biopsy tested positive for stage-four lung cancer, additional biopsy results showed that he did not have cancer.

In order to reduce the risk of a diagnosis error like this one occurring in the future, it’s important to identify all the causes that contributed to the issue. We can capture these cause-and-effect relationships in a Cause Map, or visual root cause analysis. The first step in the Cause Mapping process is to capture the impacts to the goals. In this case, there was a potential safety impact to the patient receiving unneeded chemotherapy, which could have potentially caused a worsening of the actual disease from which he was suffering. The patient services goal was impacted by the misdiagnosis and the property and labor goals were both impacted by the potential for unneeded treatment, as can occur with any misdiagnosis.

Once the impacts to the goals have been determined, the next step is to determine the cause and effect relationships by beginning with an impacted goal and asking “Why” questions. The misdiagnosis resulted from the contamination of a biopsy sample sent to the lab to determine the pathology of the disease. The patient’s lab sample was contaminated with stage-four lung cancer from another patient. (DNA testing confirmed the presence of both the patient’s biopsy sample and tissue from a sample of the lung cancer sufferer.) The presence of DNA from both samples indicates that they were cross-contaminated, though the method is still unknown. (The patient with lung cancer was properly diagnosed.) Because the two diseases are pathologically similar, it was not immediately clear that there was a problem with the sample used to make the diagnosis.

Once the patient sought another opinion, it was verified that the first biopsy sample did contain cancer cells. However, another biopsy and blood tests showed he did not have cancer. The original hospital confirmed their diagnosis of cancer even after this information until another biopsy was performed at that facility. Five months after the initial cancer diagnosis was the diagnosis updated to sarcoidosis. The patient filed a complaint with that hospital, as well as the hospital where chemotherapy was recommended, on October 23, 2014.

Once all the causes are determined, solutions can be determined that address the various causes. Because it’s still not clear how the cross-contamination at the lab occurred, an investigation specifically addressing that issue should occur, looking in detail at the specimen handling procedures and adding improvements where necessary to reduce the risk of cross-contamination. (The risk is already very low; the lab has said that it generally handles 70,000 specimens a year and this is the first contamination issue known.)

Additionally, the method for reconsidering diagnoses based on additional testing from alternate providers must be examined. Though the initial misdiagnosis in this case, based on a lab sample that clearly showed the presence of cancer cells, is understandable enough, the ensuing delay in updating the diagnosis despite heavy pushback from the patient is not. Ideally the lessons learned from this case will provide safer and more effective healthcare for everyone.

Patient Gets MRI (and a Diagnosis) Only After 24 Visits to 13 Doctors

By ThinkReliability Staff

In a tragic case of incorrect diagnosis, a 16-year-old patient died January 24, 2013, eleven months after being diagnosed with “migraines”.  In fact, the patient had a rare brain tumor (known as a disseminated oligodendroglioma-like leptomeningeal tumor).  She died eight days after receiving an MRI that finally properly diagnosed the causes of her headaches, numbness, nausea and eyesight problems.

It’s unclear if earlier diagnosis would have saved the life of the patient.  Though the prognosis is poor for a leptomeningeal tumor, a oligodendroglioma that is treated before it is disseminated gives a long-term survival chance to 80-100%.  The tumor had disseminated once it was found on the MRI, eleven months after the patient was diagnosed with migraines.  However, even if her prognosis was poor, the patient could have spent the last eleven months of her short life enjoying time with her family and friends, instead of making 24 trips to 13 different doctors and, in one particularly devastating appointment, being accused of “putting the symptoms on”.

Although the coroner at the inquest said there was no need to make a formal recommendation for changes at the hospital that failed to diagnose the patient, a spokesperson for that hospital said “In the next few weeks, many of the clinicians who looked after Natasha will be meeting to discuss this sad case and ensure that any opportunities for learning are not missed.”

It is hoped that these opportunities for learning can reduce the possibility of another patient suffering as this patient did, due to a misdiagnosis.  Misdiagnosis is a common source of medical error.  According to an article by Michael Astion, MD, PhD, “Available data suggests that misdiagnoses occur in 15% or more of clinical cases, but overall there is very limited data on the frequency of misdiagnosis in medicine.”  Especially in rare clinical cases such as this one, sharing details of the disease and diagnosis may help other clinicians in the same position.

In order to effectively determine lessons learned and improvements that can be made, the details of a case need to be presented clearly and concisely.  I’ve put together the details of the case in a Cause Map, which uses cause-and-effect to demonstrate the linkage of the issues that led to the tragedy discussed here.

In a blog discussing the cases and possible responses, Suzanne Leigh suggests that if an MRI was denied, other cheaper alternatives, such as a CT scan, be considered.  She also suggests a much more thorough review to “ensure that in the future, scans are  not withheld from patients with potentially life-threatening conditions”  and that the hospital involved should “study the flaws in the system and human errors that led to the failure of 13 doctors to order a diagnostic MRI that would have resulted in emergency treatment earlier in the disease’s progression”.  Given the tragedy of this case, the suggestions seem far more appropriate than the treatment of the patient over the last year of her life.

To view the Outline and Cause Map, please click “Download PDF” above.  Or click here to read more.