Anatomy of a Medical Mistake – Failure to Review Medical Reports

December 18, 2013

This is How Easily Medical Mistakes Can Occur – Failure to Review Medical Reports


Failure to Review Medical Report

Make sure you get the results from medical reports. Failure to review a medical report can result in serious problems for you.

I would like to tell you a true story of how easily a medical mistake can happen due to a lack of communication and follow up.*  This mistake happened because a doctor failed to review a medical report.

The Story

A patient was seeing a doctor due to long term pain in her knee. Due to a change in the pain, her doctor ordered an MRI of the knee to make sure that a tendon was not torn.

MRI complete, the patient returned to the doctor. The location which performed the MRI promised a report in 24 hours, but didn’t send one. The doctor reviewed the cd with the MRI on it and told the patient, oh you just have some scarring. Go to physical therapy. The patient went to PT.

Two weeks later the patient got a call from her family doctor. The family doctor said, “you have a torn ligament and other serious problems with this knee.”

The patient called the original doctor’s office and asked if the doctor reviewed the report. The assistant informed the patient, no he never got it. Assistant promised to get report, have doctor review it, and then call the patient back.

What Happened Here?

What happened to the patient in this case is a very common and unfortunate situation. Simply put, the doctor failed to follow up as he should have.

The Medical Mistakes

1. The MRI location failed to send a report to the ordering doctor.

2. The ordering doctor failed to follow up and get the report when the location failed to send it.

3. The ordering doctor relied on his own opinion when he should have sought the radiologist’s opinion. Radiologists are trained to review and report on MRIs.

Serious Medical Mistake?

Fortunately, in this case, the patient is ok. Unfortunately, in some cases, the consequences are very serious. For example, if the patient had been dealing with a life or death situation, say breast cancer, she could have ended up with a delayed diagnosis resulting in serious harm or even death.  In this case, if the family doctor had not checked in, PT could have gotten to a point where it caused damage to the knee. Fortunately, the family doctor checked in with the patient. Many doctors would have ignored the MRI thinking the report would have gone to the ordering doctor. This family doctor is an excellent doctor who appreciates her responsibility to her patients and obviously cares about them.

How can you prevent this kind of situation?

Follow up on your own test results. The patient should have checked to make sure the doctor had gotten the test results and that there was nothing to worry about. While it is the ordering doctor’s responsibility to follow up with the patient, this kind of medical mistake happens frequently. Patients need to step up and take responsibility for their own care to protect themselves. They cannot always rely on the doctor’s office to do what needs to be done.


*Information about the patient has been changed to preserve anonymity.  This article was written with permission of the individual.


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