CASE STUDY: Failure to Diagnose

Failure to Diagnose

It’s no surprise that the delay or failure to diagnose is the number one reason patients sue doctors. According to claims, the most frequently missed diseases, are heart attacks for adults, meningitis for children, and cancer. Let’s examine a case study in which the failure to diagnose lead to a Pulmonary Embolism resulting in Patient’s Untimely Death.

Patient Profile:

  • Male
  • Late 20s
  • Obese
  • Asthma
  • High Blood Pressure
  • Crohn’s Disease

Case Details

The patient visited his primary care physician in October and was treated for rhinitis and sinusitis. The patient’s pulse oximetry reading at the time was 99%. One month later, the patient complained of shortness of breath, coughing, and right-sided back pain.

During this visit, he saw another family medicine doctor (Dr. M) in the practice — for the first time. Dr. M ordered a chest X-ray (results were negative) and the patient’s pulse oximetry was 95%.

Dr. M diagnosed the patient with bronchitis and prescribed levofloxacin and guaifenesin.  The patient was told to return to the office if symptoms did not improve. The patient suffered a massive pulmonary embolism and died a day later.

A malpractice lawsuit was filed against Dr. M, resulting in a significantly high settlement.


What contributed to the missed diagnosis of a Pulmonary Embolism? One of the most notable contributors is faulty clinical judgment. Clinical Judgment refers to the thought process or clinical reasoning allowing healthcare providers to arrive a conclusion (clinical decision-making).

Clinical Decision-Making depends on objective and subjective information about a patient since this process is complex doctors are prone to various errors. Hense, it is not surprising that clinical judgment is a leading contributor for diagnostic errors and diagnosis-related malpractice claims.

Dr. M did not order a CT scan because she thought the patient should start the new medications in order to see if his symptoms would resolve. Unfortunately, case experts argued that the patient had a deep vein thrombosis (DVT) at the time of the visit as well as clear signs and symptoms of a Pulmonary Embolism, especially since the patient had recently had a surgical femur repair compounded by inactivity and obesity.

Documentation was another major risk issue, both content and timing perspectives. During litigation, Dr. M emphasized that the patient was in no acute distress; although the patient’s wife claimed that the patient mentioned the coughing up blood, chest pain, and sweating. None of these symptoms were noted in the patient’s health record.

Casting doubt on her credibility, Dr. M amended documentation from the patient’s final visit, 2 days after the patient’s death. The update stated that the patient did not appear to be in any apparent stress, that the shortness of breath occurred only during prolonged coughing spells, and that he denied any chest pain. Ultimately, the timing of this documentation occurred after Dr. M became aware of the patient’s death furthermore highlighting the inconsistencies in her.


Diagnosing patients who have multiple symptoms or conditions is a very challenging process. Even if eliminating diagnostic errors entirely is unrealistic, physicians have a duty to take proactive steps to improve their diagnostic process. Gathering medical history, doing complete physical exams, establishing a differential diagnosis, considering appropriate diagnostic tests and consults, and documenting the patient’s care in detail.

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