Julia Pallentino discusses the importance of thorough investigation and follow-up testing to avoid the classic medical malpractice issue of "failure to diagnose."
Cases reprinted with permission from Medical Malpractice Verdicts, Settlements and Experts, Lewis Laska, Editor, (800) 298-6288.
In March 2006, a 58-year-old Oregon attorney presented to the defendant physician complaining of shortness of breath and fatigue. Test results indicated critical anemia, and the patient received three units of packed red blood cells two days later. A single fecal occult blood test (FOBT) was performed at the hospital with negative results. The physician made a diagnosis of diet-related iron deficiency anemia and prescribed iron supplements. The patient was seen by the physician twice more.
In June 2009, the patient presented to an urgent care facility with abdominal pain and weight loss. He was diagnosed with colon cancer, which had metastasized to the liver.
The plaintiff underwent surgery to remove tumors of the liver and colon, then chemotherapy administered to treat his metastatic disease. The plaintiff will require additional chemotherapy and other treatment, and his cancer is expected to lead to a premature death.
According to a published report, a confidential settlement was reached.
This is a case of failure to diagnose, one of the most common causes of medical malpractice actions. The lesson here is that iron deficiency anemia requires a full investigation of the underlying cause—and that investigation should always include ruling out the gastrointestinal tract as a source. To do less may result in an outcome such as that seen in this case.
Here we have a 58-year-old man with significant anemia requiring transfusion. Failure to determine the source of blood loss with as near certainty as possible is clearly an error, one that will likely prove fatal. Highest on the list of diagnostic alternatives is occult bleeding. A gastrointestinal site must be ruled out. This requires referral to a gastroenterologist with appropriate evaluations, including colonoscopy and upper endoscopy when appropriate,1 with additional studies as indicated.
We know that iron deficiency was diagnosed because iron supplementation was ordered following transfusion. Iron deficiency anemia should be considered secondary to a source of bleeding until all potential causes of bleeding have been ruled out. What we do not know is whether this individual had ever undergone colonoscopy—and if so, when the procedure was last done. Diet-related anemia is a diagnosis that should have been arrived at only after causes related to the occult bleed were ruled out.
The fact that results of a single FOBT were negative does not eliminate the need to further investigate the gastrointestinal tract as a source of blood loss. Blood loss in the GI tract must be 10 mL/d or greater to generate a positive FOBT result. Furthermore, the use of FOBT in the diagnosis of iron deficiency anemia is discouraged in individuals older than 50 due to its poor predictive accuracy.1 —JP
1. Zhu A, Kaneshiro M, Kaunitz J. Evaluation and treatment of iron deficiency anemia: a gastroenterological perspective. Dig Dis Sci. 2010;55(3):548-559.