Risk Management Tools & Resources


Case Study: Delayed Cancer Diagnosis Results in Malpractice Liability for Physician Assistant and Supervising Physician


Case Details

The patient was a 53-year-old male who presented to an internal medicine practice because he had a lump in his right groin. The patient had been going to the practice for years and typically saw one physician assistant (PA) for most appointments. Over the years, he had seen the PA for various conditions, such as allergies, abdominal pain, cardiac issues, respiratory infections, hypertension, and more.

At the patient’s visit to evaluate the lump in his groin, the PA ordered a CT scan. The test was completed, and the results showed an enlarged inguinal lymph node. Whether these results were communicated to the patient is unclear. Receipt of the results was documented in the patient’s electronic health record (EHR), but no documentation from that time indicates whether the patient was notified about the results or next steps.

Two months later, at the patient’s next office visit with the PA, the EHR system was down, and the patient’s chart was not available for review. During that visit, the patient did not mention the groin mass to the PA. Several more visits to the PA occurred over the next 10 months, but the lump was never discussed.

A little more than a year later, the patient returned to the internal medicine practice, but saw a nurse practitioner (NP) at that appointment. The NP documented that the groin mass was now painful and had increased in size. The patient was referred to a general surgeon, who performed a biopsy on the enlarged inguinal lymph node. Ultimately, the patient was diagnosed with Stage III Hodgkin lymphoma.

Following the patient’s diagnosis of Hodgkin lymphoma, the PA at the internal medicine practice added a note to the patient’s health record stating that she had told the patient about the CT scan results 2 years earlier, and instructed him to follow up with a general surgeon. The patient refuted that fact and filed a malpractice suit against the PA and the supervising physician alleging delayed diagnosis.


Numerous lapses in patient care and communication occurred in this case that ultimately resulted in a delayed diagnosis and poor patient outcome. First, based on the absence of timely and thorough documentation related to the original patient encounter for the groin mass, it’s probable that the initial CT results were not communicated to the patient. Test tracking and follow-up — factors related to an organization’s “clinical systems” — are essential elements of safe patient care, yet they continue to represent an area of risk for healthcare organizations.

MedPro claims data show that failure or delay in reporting test/lab findings is a top clinical system issue in diagnosis-related malpractice allegations.1 These tracking and reporting failures call attention to the need for healthcare organizations to assess their clinical systems for vulnerabilities and devise corrective actions. Organizations should evaluate whether protocols are in place to ensure:

  • Ordered tests are scheduled, completed, and the results are received
  • The ordering practitioner reviews and signs all test results
  • A test reporting form and patient notification process are in place
  • The practitioner follows up on test results
  • Test results are filed in the correct patient record
  • Decisions about patient care are documented

Second, this particular case also points to a problem with referral tracking. The PA claimed that she did communicate the test results to the patient, and that she instructed him to follow up with a general surgeon. However, no formal referral was made, and the practice never received a consultative report from a specialist. A well-defined protocol for requesting and tracking referrals would have facilitated the patient seeing a specialist and provided an appropriate reminder to follow up when no consultative report was received.

Third, when the patient presented to the practice 2 months following his initial appointment for the groin mass, his health record was unavailable because of a technology failure. As a result, the lump was not addressed at that appointment. However, at several subsequent appointments — when the patient’s record was available — no discussion about the groin mass or the CT results took place, suggesting that the PA did not adequately review the patient’s health record to identify any outstanding issues.

The fourth lapse that occurred in this case relates to lack of appropriate supervision. The PAs and NPs in the internal medicine practice were supervised by physicians, who were tasked with providing appropriate consultation, reviewing PA and NP documentation, and providing overall oversight of PA and NP practice. The PA’s supervising physician signed off on the patient’s chart, but he never saw the patient, and no documentation indicates that the physician and PA ever discussed the test results or follow-up care plan. Further, the physician never asked why the groin mass was not discussed in subsequent visits. These oversights created questions about the amount and quality of consultation between the physician and the PA. Because the physician was responsible for supervising the PA, he also was named in the malpractice suit.

A final risk factor in this case was inadequate documentation. As stated earlier, the PA did not initially document that she notified the patient about the CT results and recommended he see a surgeon. Only after the patient was diagnosed with Stage III Hodgkin lymphoma did the PA add documentation to the patient’s record to that effect. Timely and thorough documentation — preferably at the point of care or within a specified timeframe for test/lab results — is one of the most crucial strategies that providers can implement to minimize risk. Late amendments to records can create doubt about the quality of patient care and the credibility of the provider.

In Summary

When analyzing malpractice cases, it is not uncommon to see multiple risk issues occur that ultimately lead to suboptimal patient outcomes. In this case, test tracking failures, communication issues, lax supervision, and poor documentation all converged and resulted in a delayed diagnosis for the patient and liability exposure for the PA and supervising physician. Although avoiding all instances of risk is impossible, healthcare organizations can benefit from reviewing their current protocols related to clinical systems, supervision standards and expectations, and documentation.


1 MedPro Group. (2022). Diagnostic errors: Contributing factors and risk strategies — A 10-year claims analysis. Retrieved from www.medpro.com/diagnostic-errors-contributing-factors-od

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