Case Studies

Lesson learned

Failure to Follow Up on Ordered Tests

Case Summary

On March 19, a male patient was admitted to his local hospital after four visits to the emergency department for intractable headaches. A CT scan showed sphenoid sinus abnormalities resulting in a diagnosis of acute sphenoid sinusitis. The patient improved on antibiotics and was discharged on March 22. On May 13, the patient presented to his PCP following acute onset of vertical diplopia. An MRI indicated isolated sphenoid sinus disease with a small left epidural abscess at the base of the left frontal lobe and left orbital apex, which resulted in the patient's admission to a larger facility on May 14.

The consulting ENT surgeon diagnosed sphenoid sinusitis and possible orbital apex syndrome. On May 16, the ENT surgeon performed a surgical drainage of the sphenoid sinus. During the procedure, the surgeon did not identify any tumors or lesions but did observe polypoid tissue near the opening of the sphenoid ostium, which was removed and sent for biopsy. The post-procedure diagnosis was left epidural abscess, bilateral sphenoid sinusitis, bilateral posterior ethmoiditis, and ocular diplegia of the left eye. Following surgery, the treatment plan included a six-week course of antibiotic therapy.

The pathology report of the polypoid tissue removed during surgery revealed malignant lymphoma, non-Hodgkin's B-cell type, high grade, diffuse. The pathologist making the diagnosis did not communicate the results directly to the surgeon. The report was available in the patient's electronic hospital medical record on the day of discharge. The ENT surgeon did not access the pathology results before discharge, nor did he review them subsequently utilizing his online access to the hospital EMR. It is unclear whether the lab sent the pathology report to the ENT's office, but the ENT surgeon and the patient were unaware of the diagnosis at the time of discharge and for the subsequent seven weeks.

On June 3, the patient saw the ENT surgeon for post-operative follow-up. The ENT surgeon readmitted the patient due to increasing congestion, frontal headaches, and eyelid edema. A consulting neurosurgeon found ongoing sinusitis of the left sphenoid sinus with an associated epidural collection. The patient's condition improved with medical therapy, and he was discharged on June 9.

An MRI at the patient's local hospital on June 17 indicated an enhancing abnormality in the epidural space. This prompted the patient's readmission to the larger facility on June 18. The ENT surgeon examined him and diagnosed sphenoid sinusitis/mucopyocele with resolving symptoms, improving chronic sinusitis of the ethmoid region, and a stable epidural abscess. Discharge followed treatment for this diagnosis.

The patient had follow-up MRIs performed on June 30 and July 2. These studies suggested a progression of the intracranial mass, which prompted readmission for a left craniotomy and resection of an intracranial mass. The pathology report for the removed tissue, dated July 8, indicated malignant lymphoma, non-Hodgkin's B-cell type, high grade, diffuse. The patient's treating physicians reviewed the pathology report and initiated treatment for the malignant non-Hodgkin's B-cell type lymphoma.

The patient filed A Notice of Claim against the ENT surgeon and the lab.


When the ENT surgeon performed a surgical drainage of the sphenoid sinus, he removed polypoid tissue near the opening of the sphenoid ostium and sent it for a biopsy. The biopsy of the polypoid tissue revealed malignant lymphoma, non-Hodgkin's B-cell type, high grade, diffuse. The pathologist did not verbally communicate the biopsy results to the surgeon. A consensus statement from the College of American Pathologists (CAP) states that a pathologist should communicate significant or urgent findings to the ordering provider as soon as possible. It was not clear if the lab sent the pathology report to the ENT's office.

While the pathology report was available on the hospital's electronic medical record the day the patient was discharged, the ENT surgeon did not access the results before or after the patient's discharge.

The surgeon was unaware of the pathology results for the next seven weeks, during which time the patient was seen in the surgeon's office and at the hospital. The patient underwent an unnecessary craniotomy, which was not the appropriate treatment for his type of lymphoma. The patient also experienced a seven-week delay in receiving proper treatment for the lymphoma.

The ENT surgeon's failure to evaluate the pathology results for the seven weeks he followed the patient presented defense concerns; therefore, MMIC moved to settle the claim. The claim was settled during mediation with contributions from the ENT surgeon and the pathology lab.

Risk Management Takeaways

  • Develop protocols requiring diagnostic services such as pathology and radiology to communicate unexpected, significant, or urgent results directly to the ordering provider.
  • Develop policies outlining the ordering provider's responsibility to reconcile all ordered tests and initiate follow-up for abnormal and incidental findings.
  • Develop a standard format for discharge summaries that include relevant test results.
  • Providers should develop a system to ensure they receive and review test results for inpatients, similar to the results management process in the outpatient setting.
  • Be sure that patients are notified of normal and abnormal test results. Patient portals make test results more readily available to patients.
  • Assist patients in setting up access to the patient portal.