ROLE PLAY – DIAGNOSTIC ERROR

Misread Chest X-Ray of The Patient Led to Respiratory Failure and Death

NARRATOR: Darlene, a 25-year-old female patient visits primary hospital for check-up,
she complained for headache, runny nose, cough and sore throat. She was diagnosed
by his primary care clinician with sinusitis and prescribed an antibiotic. After 5 days, she
was rushed in the emergency room and was evaluated due to fast heart rate, labored
breathing, extreme fatigue, and chest pain with cough.

Nurse: Doctor Galleno, Miss Darlene body temperature elevated to 38.2°C, she also
complains of difficulty of breathing and has low oxygen saturation.

Doctor: Give 2.5 milligrams of Albuterol via nebulizer.

Nurse: I'll administer the medicine right away Doc.

Narrator: After the administration of the medication, the patient's oxygen saturation
improved. Darlene was admitted in the hospital because of extreme fatigue.

Doctor: Nurse Jasmin, prepare Miss Darlene for Sinus and Chest X-ray Examination.

Nurse: Yes Doc.

Narrator: The nurse informed Darlene that her Doctor ordered Sinus and Chest X-ray
Examination to confirm whether she have Respiratory Infection.

Nurse: Good morning Ma'am Erica, Doc. Galleno ordered a sinus and chest x-ray for
patient Miss Darlene.

Radiologist: Okay, our schedule is clear as of the moment, we can conduct the
procedure now.

Nurse: That's good. I'll will take my leave now I'll just come back after 30mins.

Narrator: After informing the Radiologist, the nurse accompanied the patient to the X-
Ray room.

Radiologist: Ma'am, if you may please remove your brassiere and any type of jewelry in
that comfort room?

Patient: Excuse me ma'am, but where can I put my things?

Radiologist: You can put them on the table ma'am. Ok ma'am can you please go behind
the x-ray machine and place your front flat on the surface ma'am

Patient: Are we done?

Radiologist: And we're done, thank you for your cooperation ma'am. You can dress up
now in the cr.

Patient: When can I get the result?

Radiologist: Nurse Jasmin will get your X-ray results after two days ma'am, and Doctor
Galleno will inform you about the readings.

Narrator: The nurse then assists Miss Darlene to go back in her room and advise her to
take a rest. After 2 days, the nurse follow-up the results of the X-ray Examination.

Nurse: Good morning Doc. Can I get the X-ray result of Miss Darlene?

Radiologist: Yes Ma’am. Based on the x-ray result, so far, the patient doesn’t have any
problems on the lower respiratory tract but the patient’s sinuses are inflamed. You just
have to inform Doctor Galleno so the patient will receive immediate interventions.

Patient. Yes Doc, Thank you.

Narrator: The nurse immediately gives the X-ray result and inform Doctor Galleno about
the readings.

DOCTOR: So, ma’am base on the reading of the Radiologist you have Sinusitis, I’ll give
you antibiotics, a Sulfamethoxazole 2 times a day, so you can take this every 12 hours,
and acetaminophen for fever and pain and you can go home now.

NARRATOR: The doctor gives the medication and advice the patient to increase fluid
intake and take a rest.

PATIENT: Thank you Doc.

NARRATOR: After 2 days the patients feel a sharp or stabbing chest pain that gets
worse when breathe deeply and cough which produce greenish, or even bloody mucus.
The patient also having loss of appetite, low energy and fatigue. The family traveled to
the nearest hospital different from the previous one. The patient was admitted in the
hospital. The doctor ordered a Chest X-ray Examination and turns out the patient have
severe pneumonia. Due to excessive coughing the doctor ordered an antibiotic via
intravenous. The doctor also informed the relative that the patient need surgical
intervention, but before the day of the operation, the patient died of respiratory failure
associated with pneumonia.