In February 2005, Lathenia Petty went to her family physician (which insurance companies now call a “Primary Care Physician” or “PCP”) because of a lump she found in her breast. She was immediately sent to Pottstown Memorial Hospital for an ultrasound to evaluate it. The ultrasound reported that the mass was suspicious for cancer, and recommended a biopsy and here, the story becomes an example of Murphy’s Law.
The Imaging Department at the hospital faxed the report to an outdated telephone number that they believed belonged to Ms. Petty’s PCP. Naturally, since the number was wrong, her PCP never received the report and, apparently no paper copy was mailed out; presumably in an effort to save money for the hospital by being “paperless.” As is usual, a note was placed into Ms. Petty’s chart to follow up on the test results, but apparently became loss in the morass of paper that most patient charts have become; being stuffed with two inches of referral forms from HMO’s, and a dozen other irrelevant document types that clutter the chart and squeeze the real clinical notes out.
During the next several months, nothing was followed up because her PCP didn’t remember, and she never asked about it despite the lump growing larger. Not until the following December, when she finally noted that the lump was still there, was she “referred” to a surgeon for biopsy, and then she was left to find a surgeon who accepted her insurance, on her own. Most likely, though, she was handed the insurance company list of surgeons, which is usually so out of date that hours can be spent finding one who still accepts a particular insurance, and told to keep calling surgeons on the list until she found one her insurance would pay for because neither physicians nor their staff spend hours doing this for ten patients each day, and still care for the remaining patients.
Ultimately, because of the delay in diagnosis and treatment, Lathenia Petty died. A lawsuit (with the trial beginning today) was filed which asks the question – “who is to blame for her death?” Unfortunately, the answer is everyone and no one. At each step in the process, errors and omissions were made. Her PCP should have had a system in place to follow up on reports that have not been received for more than a week or so after a test was done, and the notes should have flagged the issue for future visits. The Imaging department should have made sure its fax numbers were accurate, mailed paper copies of reports as a follow-up to the faxed reports, and followed up on “positive” reports. The insurance companies should maintain accurate and up-to-date lists of the physicians they have on their panels . . . I could go on endlessly, but there is one person not charged with negligence in the lawsuit that had the greatest responsibility, and did not accept it – Lathenia Petty, herself.
Mistakes were made at every turn in a health care system that everyone acknowledges is not merely broken, but shattered. When bad things happen, though, we always look for others to blame. Had Ms. Petty reminded her PCP at the next visit that her lump was still present (or merely demanded her test results), action would have been taken then, and her death, possibly, avoided. Had she called her PCP during the ensuing months to report the “lump” growing or remaining (or simply reported it at each visit), action would have followed and her death possibly avoided. The answer here is both simple and profound. While mistakes were made by others, the most serious mistake, and the one most responsible for her death was the one she made in failing to accept responsibility for her own life. When we abdicate that authority to others, we invite disaster regardless of Electronic Medical Records, and so the most negligent person in the mix was Ms. Petty; a fatal victim of her own failures.
