Risk Management

Failure to Diagnose Pseudomonas Infection

By Stacey Meyer

OMIC Assistant Claims Manager

Digest, Spring 2002

Allegation
Delay in diagnosing and treating pseudomonas infection.

Disposition
Case settled on behalf of ER physician with a nuisance amount contributed by insured ophthalmologist.

Case Summary
A 62-year old male with a history of contact lens wear presented to the ER with complaints of pain, redness, and itching in his right eye. The ER physician examined the patient and found a tearful, hyperemic right eye and a central corneal abrasion. He irrigated the eye and treated it with Gentamicin and a patch. The patient was asked to return the following day, at which time he presented with severe pain, discharge, sensitivity to light, and inability to see. The same ER physician performed a slit lamp examination, which revealed that the corneal abrasion had doubled in size. He did not perform a visual acuity exam. The ER physician contacted the on-call ophthalmologist, who gave instructions for the patient to keep the eye patch on for 24 hours and either return to the ER the following day, which was Sunday, or follow up at his office on Monday.

The patient self-referred to another ophthalmologist on Monday and was found to have a severe, advanced inflammation of the cornea and markedly reduced vision. A culture of the eye was positive for pseudomonas. The patient underwent a corneal transplant but subsequently lost all vision in the right eye.

Analysis

The plaintiff alleged that the ER physician performed an inadequate eye examination, failed to suspect corneal infection, and failed to ensure that an ophthalmologist examined him when he returned the following day. His expert opined that the on-call ophthalmologist was equally at faulty for failing to appreciate the seriousness of the patient’s complaint and for not coming into the ER to examine the patient on Saturday when he received the call, regardless of whether the ER physician requested such an examination. According to the plaintiff’s expert, the ophthalmologist should have been suspicious of the corneal ulcer given the history of the patient’s condition, his failure to improve, and the fact that the corneal abrasion had doubled in size overnight.

OMIC’s defense expert countered that the insured ophthalmologist made a reasonable assessment that this was a non-urgent situation based upon the description provided by the ER physician. Further, lack of any evidence of a corneal infiltrate or inflammatory response effectively ruled out a significant infectious or inflammatory process of the cornea and was compatible with a traumatic corneal abrasion. Since the insured was not asked to see the patient but only to make suggestions for the patient’s care, the defense maintained that the insured’s recommendation to continue treatment with cycloplegics and re-patching was reasonable.

OMIC’s defense team filed a Motion for Summary Judgment on the legal issue of whether there was in fact a physician-patient relationship between the insured and the plaintiff. Unfortunately, the court denied the motion and held that a factual legal issue did exist. The defense team and the insured agreed this would be a difficult case to argue before a jury and settled on behalf of the ER physician with a nuisance amount contributed by the insured ophthalmologist.

Risk Management Principles
It is common practice for an on-call specialist to rely on the examination of the ER physician. Yet, as this case demonstrates, while the ER physician retains primary responsibility for the patient’s care, the on-call physician also can be held accountable and responsible for the patient’s outcome. It is up to the on-call specialist to elicit enough factual information to ensure that the ER physician has thoroughly examined the patient and that the signs and symptoms reported by the ER physician are complete and accurate.

Often in such cases, a dispute arises over what was said by the two physicians. Documenting the details of a telephone conversation with an ER physician is an important as documenting the findings of an office examination. Recollections of what was discussed weeks and months later are unreliable and open to dispute, especially when the liability of either party depends on these details.