Delayed Diagnosis of Venous Thromboembolism Resulting from Multiple System Errors

1University of New Mexico School of Medicine, Albuquerque, NM
2University of New Mexico Hospitals, Albuquerque, NM

Meeting: Hospital Medicine 2011, May 10-13, Dallas, Texas.

Abstract number: 269

Case Presentation:

A 55‐year‐old man with developmental delay underwent cervical fusion. He was discharged with a urinary catheter to a rehabilitation center. He developed urosepsis and was readmitted to the hospital 1 month later. On this admission, marked unilateral left leg edema was noted. Venous ultrasonography was performed 2 days later. The performing technician interpreted the examination as negative and wrote a preliminary paper report. This was reviewed by a resident physician, who noted the preliminary results in the electronic medical record (EMR). The preliminary report was left on the ward, never scanned into the EMR, and ultimately lost. Two days later, the interpreting physician (who had no knowledge of the preliminary report) interpreted the ultrasound as showing extensive thrombus of the external iliac and common femoral veins. Assuming that the ordering physicians were aware of these positive results via the preliminary report, the interpreting physician dictated a report, but did not notify the ordering physician. The report was not transcribed into the EMR until 21 days after it was performed. Being unaware of the final report, the patient's physicians transferred him back to the rehabilitation center without anticoagulant therapy. He developed hypotension and altered mental status and was admitted a third time 25 days after the positive venous ultrasound. The ultrasound results were not uncovered in the EMR by the admitting physicians. He was treated for urosepsis and Clostridium difficile colitis. Once stable, he was discharged to the rehabilitation center but was readmitted a fourth time with hypotension. During that admission, the patient suffered transient atrial fibrillation and new‐onset pulmonary hypertension. The positive ultrasound was finally uncovered during a routine venous thromboembolism prophylaxis compliance audit 6 weeks after it was performed. The patient's physician at the rehabilitation center was contacted, and anticoagulation therapy was instituted.


This patient suffered venous thrombosis for which treatment was delayed 6 weeks. A root cause analysis uncovered multiple system errors. These included lack of knowledge by the interpreting physician of the preliminary report results, transcription delays, inconsistent notification of delayed results, inconsistent filing of preliminary paper reports in the EMR, incomplete review of EMR records by admitting physicians, inconsistent communication between technicians and interpreting physicians, and lack of positive reporting redundancy and failsafe reporting systems.


Review of this case of delayed diagnosis resulted in detection of multiple systems errors that can affect patient safety.


S. Emil ‐ none; A. Burnett ‐ none

To cite this abstract:

Emil S, Burnett A. Delayed Diagnosis of Venous Thromboembolism Resulting from Multiple System Errors. Abstract published at Hospital Medicine 2011, May 10-13, Dallas, Texas. Abstract 269. Journal of Hospital Medicine. 2011; 6 (suppl 2). Accessed March 30, 2020.

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