University of Phoenix
DHA/712 Risk Management in Complex Organizations
Professor Gerald Griffin
February 9, 2012
On a Friday afternoon a 46-year-old female veteran with a persistent cough, raspy breathing, and fever came into the Veteran Affairs Medical Center Emergency Department. The physician on staff examined the female veteran, and did not find any specific abnormalities. The physician still ordered chest radiography and reviewed the radiographs once she received the radiographs. The emergency physician on staff released the female veteran with a diagnosis of an upper respiratory infection and asked the female veteran to call her primary care physician if her symptoms did not cease. The emergency physician chose not to call the radiologist who was on call but at home and could be reached by telephone. The following week day, the radiologist was on duty after he read the radiographs and recorded a report that stated, “Chest is most likely normal. However, there is a small ill-defined density in the right upper lobe, most likely representing a scar. If no previous films are available for comparison, CT scan should be considered for further evaluation.” During the time he read the radiographs, the emergency physician had already read the radiographs as normal. One year later, the same female veteran was referred by her primary care physician to the Veteran Affairs Medical Center’s radiology department for chest radiography because of an ongoing cough. The radiologist who read the chest radiographs a year ago read the new radiographs. The new radiographs showed a 2.5 cm lesion on the female veteran’s right upper lobe, same area to where the radiologist had seen the density on the previous radiographs. Moderated mediastinal lymphadenopathy was also present. The findings were evident and suspect for carcinoma, and the diagnosis of a small cell carcinoma was...