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Patient kept in dark as cancer spread

Division of Licensing and Protection accepts ‘plan of corrections’ from Brattleboro Memorial Hospital

BRATTLEBORO—In March 2014, a radiologist spotted a “highly suspicious,” possibly cancerous mass on the kidney of a Brattleboro Memorial Hospital patient.

But state inspectors say it took two-and-a-half years for that patient to learn of the problem. By then, the cancer had spread to the patient’s lungs, and surgeons had to remove the kidney.

New documents show that the state has cited BMH both for the notification error and for initially failing to thoroughly investigate the incident. They are the kinds of violations that could, if left unaddressed, jeopardize a hospital’s access to Medicare and Medicaid funding.

However, the state Division of Licensing and Protection has accepted the hospital’s “plan of corrections.” It includes new communication and review strategies designed to not allow such test results to fall through the cracks again.

“We take this matter and all patient complaints extremely seriously and, as reported, we have instituted multiple system improvements to our care processes,” said Gina Pattison, BMH’s development and marketing director.

BMH, a 61-bed hospital, has come under the Division of Licensing and Protection’s scrutiny once before in the past year. That case involved two mental health patients and reflected larger, statewide problems due to a lack of available treatment for such patients.

The new case also involves alleged patient rights concerns, but in a very different context.

A ’highly suspicious’ mass

State documents say the patient, whose name isn’t disclosed, first visited the hospital’s emergency department on March 24, 2014, and complained of lower abdominal pain. Treatment included intravenous liquids, pain medication, and a CT scan.

The initial goal of the scan was to determine whether the patient was suffering from diverticulitis, an inflammation or infection in the colon. And the radiologist did, in fact, find evidence of that condition.

But the radiologist also included an addendum report that warned of a mass on the patient’s left kidney. “This appearance of a solid renal mass is highly suspicious for a renal cell carcinoma (cancer),” the reports said.

The radiologist recommended biopsy and a follow-up with a urologist and discussed these findings with an emergency department physician, according to the state’s findings.

The patient was discharged that same day with a prescription for antibiotics and instructions for managing diverticulitis. But there is no record, officials say, that the patient was told of the potentially cancerous mass.

Nor did any such discussion happen three days later when the patient returned to the emergency department complaining of similar symptoms. The patient was treated and discharged the next day, state documents show.

On Sept. 20 of last year, the patient was back at BMH with complaints including bloody urine. The patient was discharged with instructions to see a urologist, only to return again on Sept. 28 with worsening symptoms.

This time, a new CT scan showed cancer that had occupied most of the patient’s left kidney as well as “multiple lung metastases.” Surgery quickly followed.

Sometime during that hospital stay, the hospital’s chief medical officer, Kathleen McGraw, was made aware of the potential missed diagnosis in 2014, documents say. McGraw met with the patient after discharge last fall and offered “full disclosure” of the situation.

The state’s documents don’t indicate how the patient has fared since then.

Failure to disclose

State officials say the hospital’s initial failure to disclose the 2014 test results constitutes a violation of patient rights. Those rights include “being informed of his or her health status, being involved in care planning and treatment and being able to request or refuse treatment.”

The state says BMH also didn’t meet “quality assurance/performance improvement” standards after finding out about the error.

In addition to failing to thoroughly investigate the cause of the incident, BMH “failed to develop and implement hospital-wide preventive actions to assure that adverse events will not recur,” officials wrote.

The state documented a number of examples, including:

• In an interview with the state late last month, the chief medical officer told officials that a confidential peer review of the incident — a review that began in October — hadn’t yet been completed.

• The hospital’s executive director of quality, utilization, and care management attributed the problem to an “M.D. handoff issue” and also cited “ongoing problems and challenges” with the electronic medical records system.

But there had been no “root cause analysis” of the cancer patient’s lack of notification, officials wrote.

• As of March 21, the hospital’s director of health information management hadn’t been asked to review how addendums — like the one that might have flagged the patient’s cancer in 2014 — are managed in electronic medical records.

“We have to figure something out,” the director told state inspectors.

• Also, as of late March, two other hospital administrators told the state that they were still unaware of the cancer patient’s “adverse event.” One of those administrators also professed ignorance of a regular “unexpected findings” report now issued to radiologists at the hospital.

Overall, the state’s report says, the hospital failed “to interview individuals whose departments were associated with the [cancer patient’s] event and who may have been able to assist in the implementation of preventative action when first acknowledged in September 2016.”

That has recently changed, though.

BMH’s submissions to the state show that the hospital is developing a new process to handle so-called “unexpected findings.” The hospital says “redundancies in communication have been affected in order to mitigate the potential for clinicians to unintentionally neglect pertinent clinical results.”

For example, in the event that a doctor can’t be contacted or doesn’t respond to notification of an unexpected test finding, radiologists will send a letter to the patient and doctor “summarizing the findings along with their recommended course of action.”

The hospital also will be maintaining an “unexpected findings” log, described as a documentation and tracking system. Use of that system will be monitored by the hospital’s Quality Department “to ascertain compliance and, ultimately, patient outcomes,” administrators wrote.

State officials also will be watching. Because the Division of Licensing and Protection found two compliance issues, “the state will have to conduct a follow-up visit to assure that the hospital is back in compliance,” said Suzanne Leavitt, the division’s assistant director.

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Originally published in The Commons issue #404 (Wednesday, April 19, 2017).

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