Legal Review & Commentary
Failure to timely diagnose tuberculosis leads to death, confidential settlement
By Jon T. Gatto, Esq., Blake J. Delaney, Esq., Buchanan Ingersoll & Rooney, Tampa, FL
News: A man exhibiting tuberculosis-like symptoms went to a clinic for treatment. Tests were ordered, including an analysis by the state health department, after which it was determined that the man was suffering from a disease related to tuberculosis called Mycobacterium avium. Several months later, the man presented to the emergency department with ear pain and an upper respiratory infection. He died two weeks later. An autopsy showed tuberculosis meningitis and myelitis. The patient's family sued his treating providers and the state health department for failing to timely diagnose the man's tuberculosis. The plaintiff reached a confidential settlement during trial with the health department and the clinic physician.
Background: A 34-year-old migrant farm worker went to a clinic and was given a tuberculosis skin test to determine if he had developed an immune response to the bacterium that causes tuberculosis. Based on the positive test results, blood was drawn and a chest X-ray was ordered. The man was given a mask to wear so as to protect others from contracting his potential tuberculosis.
A few weeks later, when the man returned to the clinic, a general practitioner diagnosed the man with possible active tuberculosis and administered a test to determine whether he had an active tuberculosis infection, a related infection, or tuberculosis-like symptoms attributable to another cause. The man was ordered to continue wearing a mask at all times.
The state health department's analysis of the test showed that the man did not have active tuberculosis but rather a related disease called M. avium complex. The clinic's physician reviewed the test results with the man and advised him that while it was likely he did not have tuberculosis, it could not be definitively ruled out until he saw a pulmonologist. But the man did not consult with a pulmonologist or follow up with the clinic.
Nine months later, the man returned to the clinic experiencing cold symptoms, including fever, cough, and ear pain. Doctors diagnosed an upper respiratory infection and discharged the patient with medication and instructions to go to an emergency department if his fever did not subside within a few hours or if he experienced shortness of breath later that night. A follow-up appointment at the clinic was scheduled for the next day.
Six days later, the man went to an emergency department complaining of persistent vomiting and with signs of electrolyte imbalance. A lumbar tap was performed, but the spinal fluid was equivocal. The man was transferred to two other hospitals before he died. An autopsy showed tuberculosis meningitis and myelitis.
The man's estate sued the patient's treating physician at the clinic, the hospital, the emergency department physicians, and the state health department. It claimed that they failed to timely diagnose his tuberculosis. The estate's claimed damages were past and future lost earnings, estimated at $460,000, past and future pain and suffering, and loss of support and services. The estate dismissed the emergency physicians shortly after trial began and settled with the health department and the clinic physician for an undisclosed amount.
What this means to you: "What an interesting case!" says Leilani Kicklighter, RN, ARM, MBA, CPHRM, LHRM, consultant/principal of The Kicklighter Group in Tamarac, FL, which focuses on risk management consulting services, and past president of the American Society for Health Care Risk Management. "This sequence of events reflects the many health care errors that can result from multiple handoffs and multiple caregivers as a result of lack of communication and lack of knowledge," she says. "One wonders if an accessible, master electronic medical record would have prevented this ultimate, untoward outcome. Because this patient was a migrant farm worker, one wonders whether he had health care benefits and whether or not a lack of health care benefits may have contributed to this unfortunate sequence of events particularly the failure to follow through with specialist care. What is more, one wonders whether language, cultural, or financial factors had a role in this scenario."
Tuberculosis (TB) is caused by Mycobacterium tuberculosis, not M. avium. M. avium is an atypical, acid-fast, opportunistic organism that is primarily a pulmonary pathogen.
Diseases and conditions caused by the avium organism are not reportable to the health department. On the contrary, the presence of M. tuberculosis must be reported. Tuberculosis is spread through airborne droplets, while the M. avium organism is not.
This patient ultimately expired from tuberculosis meningitis and myelitis. Tuberculosis can infect body organs such as the kidneys, bones, and meninges, as it did in this case.
Patients who present to a clinic who are exhibiting signs and symptoms of, or who have a differential diagnosis of tuberculosis, should be referred to the state health department or an infectious disease specialist for definitive diagnosis and appropriate care, says Kicklighter. At the time of this patient's initial visit to the clinic, tests showed the M. avium. He also was given a skin test for tuberculosis. However, a tuberculosis skin test [purified protein derivative (PPD)] needs to be "read" in three days. In this case, the patient did not return to the clinic for a few weeks, so the test results may not have been read in a timely manner. The test results from the state health department showed that at the time the tests were done that he did not have active tuberculosis.
It is unclear in this case whether the patient had a positive PPD. If he were in an immunosuppressed state, which does not seem to have been determined, he could have activated dormant tuberculosis as he became more debilitated or become exposed to active tuberculosis, which may have caused the active disease in him that went undetected.
When this patient was seen at the clinic for the second time, by a different physician, he was referred to a pulmonologist for a definitive diagnosis of tuberculosis. The patient never saw the pulmonologist. At this point, it is unclear whether he ever made the appointment or whether the clinic did make the appointment and the patient did not keep it. It may have been that language, culture, or financial issues due to lack of health insurance contributed to this failure to follow up with the pulmonologist.
Nine months later, when the patient presented first to the clinic and shortly thereafter (within six days) to the emergency department with the signs and symptoms that ultimately led to a lumbar puncture, the patient was transferred out. Apparently he was transferred to two hospitals before expiring. Again, the reasons for the multiple transfers are unclear, but the nature of this patient raises speculation that there may have been a violation of the Emergency Medical Treatment and Labor Act..
What this means to risk management departments is that they should work with the medical staff to ensure complete documentation when multiple physicians are involved in clinical patient care. Kicklighter says that, while cost may be an issue, risk managers should work with management to develop a short- and long-term plan for implementing an electronic medical records system. Such a system could improve the quality of information exchanged in connection with handoffs between caregivers and help prevent situations such as this from happening, she says. Meaningful peer review also may assist. More specific to this case, risk management can provide educational sessions for physicians and physician extenders to provide a better understanding of the differences between Mycobacterium avium and of Mycobac-terium tuberculosis. Also, the best practices to use in case of these diagnoses can be explained. Finally, risk management can work with physicians and physician extenders and the state health department in their area to establish stronger lines of communication and methods to facilitate follow-up with patients who are immigrants or migrant farm workers and who may have language, cultural, or financial issues that interfere with proper care.
Reference
Highlands County (FL) Circuit Court, Case No. GC02-612.
News: A man exhibiting tuberculosis-like symptoms went to a clinic for treatment. Tests were ordered, including an analysis by the state health department, after which it was determined that the man was suffering from a disease related to tuberculosis called Mycobacterium avium. Several months later, the man presented to the emergency department with ear pain and an upper respiratory infection. He died two weeks later.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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