How Did Physicians Miss This Dangerous Abscess?

This case illustrates why physicians need to double- or triple-check test results before making a diagnosis…, Malpractice Case: How Did Physicians Miss This Dangerous Abscess, Jacqueline Ross, PhD, RN; David L. Feldman, MD, MBA


An obese woman in her late forties came in to the emergency department complaining of severe shoulder pain.
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, the ED physician spoke to the radiologist, who said the MRI on the patient was unremarkable.
The ED physician did not review the MRI scan and told the patient the MRI was normal.


The next morning, the patient was taken by ambulance to a different hospital. 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. She has returned to her baseline health.


The patient sued the original ED physician and the hospital for failure to diagnose. The defense 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.


The case settled for a small amount.


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