Case Analysis: a problem of perception

He was my patient. A serious and educated 55- year-old man with a diagnosis of metastatic colon cancer waiting to start chemotherapy. I started my usual physical examination, normal conjuntival coloration, normal heart sounds, but something keeps my attention: no ventilation in the left basal lung. No signs of pleural effusion or atelectasia. No dyspnea or thoracic pain. I asked for a thoracic X-ray but nothing attracts my attention.

CLINICAL EVOLUTION: The radiologist did not report  findings but he recommended a CAT scan because he had a doubt about a left pulmonary consolidation. After I saw the scan the patient was treated with a pleural tube with continuous suctioning. The treatment for cancer was delayed at least for five days.

In the next picture we show the result of the CAT scan:

FINAL DIAGNOSIS: Pneumothorax after  Port-A-Cath device placement

TYPE  OF DIAGNOSIS ERROR: Delayed Diagnosis with cognitive(clinical reasoning and test interpretation) and system aspects.

COGNITIVE ASPECTS:

 Overconfidence: I assumed that the finding was not related to the disease and I couldn´t explain it based on my experience. I knew  something was wrong but I  thought it was not important.

Wrong test interpretation: initially the radiologist failed to detect the pneumothorax, possibly because it was in a small area.

SYSTEM ASPECTS:

Communication: the placement of the device was not recorded in the medical record. The device is not visible. Even after looking at the X-ray my mind was not able to make a connection between the physical sign and the device.

Supervision: no protocols were  established to warn when some signs or symptoms were present after the placement of a device.

IMPROVEMENT RECOMMENDATIONS:

.Comment with your colleague the abnormal signs that you can detect during the physical examination of a patient.

.If a procedure is done before having examined the patient thinks it can be related with this  manipulation.

.Inform in detail to the radiologist about the findings in the physical examination.

.Special alerts must be set up to inform the clinician about the details of the placement.