System Failures Still Cause Preventable Diagnostic Errors

Guest author Lori Atkinson talks about missed or delayed diagnoses due to tracking system failures and how to prevent them.

In over 30 years of work in risk management and patient safety, I have been consulting with medical office teams on how to reduce diagnostic (Dx) errors due to failures in test, appointment, and referral tracking systems. While technology and electronic health records (EHRs) have changed the workflow and the systems used, they have not improved this process of care. We still see delayed and missed diagnoses due to these system failures.

Diagnostic Errors are Frequent and Expensive for Medical Offices

An analysis of a subset of our malpractice claims found that Dx error claims are the most expensive for medical offices, contributing to almost half the costs. This is mainly due to the injury severity caused by a missed or delayed diagnosis. Dx error claims are #2 in occurrence in medical offices.

When we investigate the risk factors contributing to these diagnostic errors, we find problems with tracking systems in almost half of claims. Because tracking systems are primarily delegated to office team members; an accurate and timely diagnosis depends as much on the team and the office’s systems as it does on the diagnosticians themselves.

The top three missed diagnoses in our analysis were:

• Cancers - primarily breast, lung, and skin
• Vascular events - stroke, heart attack, and venous thromboembolism
• Infections - appendicitis, meningitis, and sepsis

Here is a case example: A primary care physician (PCP) saw a 45-year-old woman for a routine exam and ordered a screening mammogram. The radiologist inter­preted the mammogram as showing a region of potential distortion within the upper outer quadrant of the left breast and recommended additional imaging. The radiologist initiated an electronic process to generate and send a letter to the woman and a report to her PCP indicating that the mammogram showed find­ings that required additional imaging studies to rule out a serious condition.

One year later, the woman saw her PCP, complaining of a palpable lump in her left breast. The PCP ordered a mammogram that revealed a solid lesion in the upper-outer quadrant of the left breast that was highly suspicious of cancer. Following a biopsy, she was diagnosed with breast cancer and underwent pre-operative chemotherapy followed by a mastectomy and radiation to the left breast.

The woman filed a malpractice claim against the PCP, the radiologist, and the radiology center, alleging failure to timely diagnose breast cancer and loss of chance of survival. The investigation of this claim revealed that the radiologist correctly interpreted the mammogram. However, a system-generated letter to the patient and a report to the ordering clinician were not sent due to a failure in the reporting technology. Neither the patient nor the PCP received the communications about the abnormal mammogram.

A root cause analysis of this adverse event included a health information technology (HIT) investiga­tion that found a recent software update triggered a failure in the reporting system and that many patients could have been affected.

The experts who reviewed the claim were critical of the radiology center because they had no quality assurance process to evaluate whether system-gener­ated letters and reports were being received by patients and ordering clinicians.

The PCP’s clinic was also criticized for not hav­ing a tracking system to ensure that image reports were received, reviewed, and communicated for all ordered tests. The patient testified that she assumed “no news was good news” when she did not receive communication about the mammogram results.

How to Prevent Tracking Failures

Radiology and primary care practices can perform a Failure Modes and Effects Analysis (FMEA), a prospective process, on test/image management and reporting processes to identify where and how the process might fail, the likelihood the failure will be detected, the effect of the failure on the patient, and what can be done to prevent the failure. Using the results of the FMEA, care processes can be re-engineered to be more reliable and safer.

A root cause analysis (RCA) can also be performed after a failure to diagnose events like this one to determine the contributing factors to the system failure and then implement tactics to improve those steps in the care process.

HIT team members or consultants can assist radiology practices with integrating imaging systems with a closed-loop workflow that includes patient letters, ordering clinician reports and summaries, biopsy results, recommendations, and tracking reminders. HIT team members can also assist primary care practices in fully implementing the tracking features of their EHRs.                                                                     

Curi members can access our new Risk Management Guide: Test, Appointment, and Referral Tracking here. 

If you have any questions about this topic, please call 800-662-7917 to speak with one of Curi Advisory’s Risk Solutions experts.