Sad Story ..

Figure 1: CT Scan showing ruptured aortic aneurysm


A 63-year-old man who had been complaining for 2 weeks of “aching” in his lower abdomen was referred by his family physician to the radiology department of a hospital for CT of the abdomen and pelvis.

Two days after the CT examination, the physician telephoned a secretary in the radiology department, stating that he had not received a report of the CT. The secretary replied that she would investigate the matter and forward a report to him. Four days later, a nurse at the physician’s office again telephoned the radiology department to complain that a report of the CT examination still had not been received.

There is no evidence that anyone in the radiology department followed up on these telephone calls. Eight days after the CT examination, the patient experienced acute onset of excruciating pain in the lower abdomen and back. The patient was rushed to the emergency department of the hospital, where he was found to be profoundly hypotensive and tachycardic. Sonography was ordered and disclosed a 7-cm-diameter dissecting aneurysm of the abdominal aorta.

The patient underwent emergency surgery, which revealed a ruptured abdominal aortic aneurysm. Surgical repair was attempted, but the patient died on the operating room table.

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Based on article
John J. Smith and Leonard Berlin "PACSand the Loss of Patient Examination Records", Malpractice Issues in Radiology, American Journal of Roentgenology, 2001

To Download full articlehttp://www.ajronline.org/cgi/reprint/176/6/1381.pdf