Safety Nets for Safer Care

A 33-year-old woman went to the Emergency Department (ED) for abdominal pain and intermittent rectal bleeding. The attending physician ordered a colonoscopy, but it was never completed. The patient was diagnosed with colon cancer two years after her initial ED visit, and she passed away within a year.

No one will ever know if having that initial follow-up would have changed her outcome, but an earlier diagnosis might have offered a better chance for survival. Preventing patients from falling through the cracks in the system is a constant challenge, and some health care organizations have turned to ambulatory safety nets to help address systemic and communication breakdowns in the continuity of care.

Looking at the Harvard medical community as an example, CRICO’s medical malpractice data show a missed or delayed diagnosis accounted for more than 30% of all indemnity payments made between 2013 to 2022, and more than 80% of those cases took place in an ambulatory setting.

To effectively drive change on the ground as an insurer, CRICO convened its members to consider system-wide solutions to target this high-risk area, and the participants established the Ambulatory Safety Net Collaborative.

In 2022, the collaborative implemented a colorectal cancer ambulatory safety net, which scans a registry of patients who had no follow-up after an abnormal stool-based test or had missed or delayed a colonoscopy. Because of the myriad barriers to follow-up care–from transportation and cost issues to immobilizing anxiety–a patient navigator is engaged to attempt to contact the patient directly to support them in successfully scheduling and completing a colonoscopy.

As of February 2024, participants have identified more than 3,000 patients overdue for follow-up on abnormal colorectal cancer screenings. More than half of those patients have successfully scheduled or completed a colonoscopy.

This is only the beginning for the collaborative: A behavioral health safety net is also underway within the collaborative, and additional Ambulatory Safety Net (ASNs) targeting breast, lung, and prostate cancers will be rolled out in the coming years. In partnership with Ariadne Labs, CRICO also developed recommendations to help guide organizations in adopting and implementing their own ambulatory safety nets.

Clinician Corner

“To save lives like this is just amazing … I don’t know any physician who either hasn’t had a problem with this where they’ve missed something, or they have a colleague who missed something. But the devastating impact on the patient and the family is very difficult for all parties concerned. I think the physicians themselves have some reassurance that they may have a backup plan in case they themselves just didn’t see a result or are unaware of it. And I think collectively, we’re all just trying to do the right thing by our patients. Certainly, helps with malpractice risk, but as a provider, just knowing somebody has got my back, that’s huge.”

- Dr. Denise Mayo, Medical Director of Mass General Brigham Ambulatory Safety Net

Featured on CRICO’s Safety Net Podcast: A Net to Catch Patients at Risk of Falling Through the Cracks

Additional Material

• Developing and Implementing a Colorectal Cancer Ambulatory Safety Net - Ariadne Labs 
• Jury finds M.D. negligent for not following up on lung nodule | Massachusetts Lawyers Weekly (masslawyersweekly.com)
• Electronic Clinical Surveillance to Improve Outpatient Care: Diverse Applications within an Integrated Delivery System - PMC (nih.gov)