Case Study
Are We Properly Tracking Test Results and Referrals?
Category: Closed Loop
Risk: Missed diagnosis of celiac disease.
Three years after being tested for celiac disease, a delayed diagnosis is uncovered.
Diagnostic Process of Care in Ambulatory Diagnosis Cases*
Inadequate patient assessment is a contributing factor in 4% of CRICO (5% of Candello) ambulatory cases alleging a missed or delayed diagnosis.
| | | Percent of Cases** | ||
| | Step | CRICO (N=175) | Candello† (N=2,919) | |
| 1.
| Patient notes problem and seeks care | 1% | 1% | |
| 2. | History and physical
| 10% | 8% | |
| 3. | Patient assessment/evaluation of symptoms | 35% | 31% | |
| 4. | Diagnostic processing | 43% | 35% | |
| 5. | Order of diagnostic/lab test | 40% | 31% | |
| 6. | Performance of tests | 5% | 3% | |
| 7. | Interpretation of tests | 37% | 23% | |
| 8. | Receipt/transmittal of test results to provider | 4% | 5% | |
| 9. | Physician follow up with patient | 21% | 18% | |
| 10. | Referral management | 13% | 21% | |
| 11. | Provider-to-provider communication | 12% | 12% | |
| 12. | Patient compliance with follow-up plan | 14% | 17% | |
* Cases with claim made date 1/1/11–8/31/16
** A case will often have multiple factors identified
† Candello is CRICO’s Comparative Benchmarking System
Closed Malpractice Case
An 8-year-old with a history of forearm fractures and osteopenia was referred to an endocrinologist, who made an interim diagnosis of idiopathic juvenile osteoporosis (IJO). The girl was referred to a gastroenterologist to rule out celiac disease.
An upper endoscopy, performed by a different physician, indicated all structures appeared normal. Five days later, the pathology report was positive for celiac disease. Over the next three years, the child was treated by her gastroenterologist, endocrinologist, and orthopedic surgeon for IJO. When she developed abdominal pain and constipation, her PCP (different from three years prior) conducted a celiac test, which was positive. When asked by the endocrinologist if a patient could become celiac positive three years after a negative test, the gastroenterologist saw the previous (positive) results in the patient’s chart. (Neither the endocrinologist nor the referring gastroenterologist had ever reviewed them.)
When notified, the girl’s parents said they had been told the initial test results were negative, but couldn’t recall by whom. A gluten-free diet gradually improved the girl’s condition.
Patient Safety Vulnerabilities
- The pathologist routed the celiac test results to the gastroenterologist who performed the endoscopy, but not to any of the patient’s other caregivers.
Safer Care: Patients undergoing a test/procedure expect coordination among all of the providers involved. A system that allows abnormal results to be go unnoticed by subsequent providers needs to be assessed and fixed. - Several caregivers proceeded with a misguided treatment plan for three years after the celiac test results were reported.
Safer Care: The decision to order a test must include a commitment to close the loop all the way through reviewing and sharing the results with subsequent providers and the patient.
Practice Assessment
- Has this type of event happen at our practice?
Recommended practice: Rely on a system, rather than memory, to close the loop on the receipt of results for all ordered tests.
- What is our process for closing the loop on test results/consult reports?
Recommended practice: Obtain a baseline assessment by performing a random audit of normal and abnormal result notifications.
- Do we document an expected turnaround time for test results/consults?
Recommended practice: Develop written procedures for managing the critical results of tests and diagnostic procedures.
- What is our turnaround time goal for reporting results to a patient?
Recommended practice: Ensure that all providers involved in a single patient’s care know who is responsible/accountable for reporting test results to the provider and the patient, and the expected timing.
Recommended practice: Encourage patients to inquire about test results if they haven’t been notified.
Additional Resources
- No Review of Test Result, and Girl Suffers Wrong Dx for Years (podcast)
- CRICO’s 12-Step Diagnostic Process of Care Framework
- Testing and Results Processing
- CRICO CME Bundles
Disclaimer: The CRICO Are You Safe? cases offer suggestions for assessing and addressing patient safety and should not be construed as a standard of care.
CRICO’s mission is to provide a superior medical malpractice insurance program to our members, and to assist them in delivering the safest health care in the world. CRICO, a recognized leader in evidence-based risk management, is a group of companies owned by and serving the Harvard medical community.
How to Earn Category 2 Risk Management Credits
This Are You Safe? case study is suitable for 0.25 AMA PRA Category 2 Credit™. This activity has been designed to be suitable for .25 hours of Risk Management Study in Massachusetts. Risk Management Study is self-claimed; print and keep this page for your record keeping.
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