A Missed Gallbladder on Point-of-Care Ultrasound: Documentation and Disclosure
On an evening shift you are asked to perform an abdominal ultrasound on a 44-year-old woman with 12 hours of right upper quadrant pain, fever of 38.6 °C and a white cell count of 14.2 × 10⁹/L. The referral note states that a surgical resident performed a point-of-care ultrasound 4 hours earlier and documented "no gallstones, no wall thickening, normal gallbladder"; the patient was sent home and has now returned with worsening pain. Your scan shows a 9 mm echogenic focus with posterior acoustic shadowing in the gallbladder neck, a 5 mm wall, pericholecystic fluid and a positive sonographic Murphy sign. Afterwards the resident says "please don't put that in writing, it makes me look bad," and the patient's husband asks you in the corridor what you saw and whether his wife was sent home wrongly.
1. How do you respond to the resident's request, and what exactly do you document?
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The request cannot be accommodated, and the reason is not personal - the record is a legal and clinical document that other clinicians will rely on.
What to document:
- An objective description of the findings: the 9 mm shadowing focus in the gallbladder neck, 5 mm wall, pericholecystic fluid, positive sonographic Murphy sign, and the resulting impression of acute cholecystitis.
- The technical conditions of the examination and any limitations.
- The critical-result communication: who was told, at what time, and what was said.
What not to document:
- No editorial about the resident, no speculation about why the earlier study was negative, and no alteration or deletion of the earlier note. If a correction to your own report is needed, issue an addendum with a timestamp, never a silent edit.
It is also worth telling the resident, factually and without heat, that the earlier study can be reviewed through the departmental quality process - a false-negative point-of-care study is a recognised limitation of a focused examination, and the response should be review and training rather than concealment. Staying within your scope means describing images, not assigning blame.
2. What do you say to the patient's husband in the corridor?
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Acknowledge him, but do not interpret.
- The sonographer's role is to acquire and describe images; the diagnosis is communicated by the treating team, who have the whole clinical picture. Say that clearly and without appearing evasive.
- Do not confirm or deny that his wife was discharged inappropriately. You were not present at that decision and do not have the full record; offering an opinion would be both outside your role and potentially harmful to the clinical relationship.
- Do not disclose findings to a family member without the patient's agreement. Confirm identity and consent, and if he is her nominated contact, direct him to the treating clinician.
- What you can do concretely: tell him that the scan has been completed, that the findings have been escalated to the team looking after her, and that someone from that team will speak to them shortly. Then make sure that actually happens - the escalation should already have been made, because this is a critical finding.
Empathy is appropriate; clinical interpretation is not.
3. What quality and safety processes should this case trigger, and what should the department learn from it?
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Several separate processes should run in parallel:
- Immediate clinical escalation. Acute cholecystitis with a positive Murphy sign and pericholecystic fluid is a critical result; document the direct communication to the responsible clinician and the time.
- Discrepancy review. Refer the case to the departmental quality-assurance or peer-review meeting. The purpose is system learning - was the POCUS performed with an adequate machine, an appropriate probe and adequate depth, was the patient fasted, was the gallbladder body and neck fully scanned in two planes, and was the operator trained and credentialled for biliary POCUS?
- Credentialing and governance. Point-of-care ultrasound programmes require documented training, image archiving, and audit of a sample of studies. If images were not archived, that is itself a governance failure, because the study cannot be reviewed.
- Incident reporting. If the delay caused harm or prolonged admission, file an incident report through the formal safety system - this is separate from, and not a substitute for, talking to the patient's team.
- Support. Offer the resident a non-punitive review conversation. Blame drives concealment; systems that review discrepancies openly are the ones that catch the next case.