Pregnant Patient Dies From Hemorrhage Following Misread Ultrasound

This case involves a 35-year-old pregnant patient from Colorado who presented to the hospital with severe abdominal pain in her second trimester. An ultrasound was performed on the patient, and the sonographer interpreted fetal demise, even though he was not qualified to interpret ultrasound studies. No other doctor reviewed the ultrasound, and the patient was subsequently discharged. This was contrary to hospital policy, as she had not received a radiologist’s interpretation. As the patient was on her way home, she began to hemorrhage and returned to the ER. It was discovered that ultrasound study had shown the patient was unknowingly hemorrhaging. The patient died within a few hours. A radiology expert was sought to opine on the proper protocol for reading obstetrical ultrasounds.

Question(s) For Expert Witness

1. How often do you read obstetrical ultrasounds?

2. If a patient presents in their second trimester with abdominal pain, who should read their ultrasound and how quickly should it be done?

3. How quickly should those results be relayed back to the ER physician?

Expert Witness Response E-092292

I am subspecialty trained in abdominal imaging and I have operational experience with both community and academic hospitals with regards to turnaround times and critical results reporting. In fact, I have written and revised these policies. Who interprets the ultrasound depends on the individual hospital. There are hospitals where obstetrician performs and interprets the 2nd/3rd trimester ultrasound exams, and there are hospitals where radiologists interpret these ultrasound exams. This case sounds like it was the responsibility of the radiology department. Turnaround times are also hospital-dependent and usually set by hospital leadership if the radiology practice is hospital-based or specified in a contract if there is an independent radiology practice. How quickly the results should be relayed back to the ER is usually defined by the hospital/radiology department's critical results reporting policy. Critical results policies generally specify communicating results in 30 minutes or less and can depend on how easy or hard it is to get in touch with someone.