A 51 year-old male smoker presented to the emergency department in January, 2000, with complaint of fever, chills, productive cough and shortness of breath. Diagnosis of bronchitis was made after workup including a chest X-ray. The treating emergency department physician interpreted the chest X-ray as showing no acute infiltrates and patient was discharged with treatment for his bronchitis.

The film was interpreted by a radiologist on 1/10/00 with finding of possible abnormal mass in the left anterior chest with computed tomography recommended. The final interpretation of the chest X-ray was never communicated to the patient.

The patient was ultimately diagnosed with lung cancer and expired.

medQuest provided an emergency department expert from New York who opined that the emergency department must have a mechanism for reconciling the results of tests completed or received after a patient is discharged. The physician or other healthcare provider on the ED staff is most commonly designated as the person responsible for reviewing test results, and informing a patient or their designated physician of any clinically significant information.

This case was eventually settled with the help of this emergency department expert for a significant amount.