The underlying reasons for missed cancer claims uncovered
Delays stemmed from patients and providers
I told the patient to follow up in three months and she didn’t." "I told the patient to call for the results if he doesn’t hear from me."
Physicians might believe these responses would be an effective defense in the event of a malpractice suit, but "it’s unclear, with respect to the courts, whether that is good enough," says Saul Weingart, MD, MPP, PhD, chief medical officer at Tufts Medical Center in Boston.
"At this point in time, it’s incumbent on physicians and their practices to make sure there are mechanisms in place to follow up on test and specialist referrals as well as test results. It is important that clinicians don’t drop the ball and are sure to send multiple reminders," he says.
A 2009 study of 102 breast cancer patients found that clinicians and patients contributed to breakdowns in the diagnostic process.1 " It turned out that in a significant number of these potentially missed and delayed diagnoses, that the patient’s behavior was important," says Weingart, the study’s lead author.
Patients might fail to obtain care because they don’t understand the importance of a screening or diagnostic test, or they have difficulty getting access to care.
"The implication is that clinicians should work very, very hard on improving access," says Weingart. He recommends these practices:
• making sure that patients are evaluated quickly if they report concerning symptoms;
• educating patients about signs and symptoms that merit a quick workup, such as breast lumps, blood in stool, new difficulty urinating, and persistent cough;
• "closing the loop" on referrals, with electronic systems that alert the referring provider if the patient missed a test or failed to schedule an appointment. The provider could then send a reminder or contact the patient.
Where is the vulnerability?
Weingart says that while most practices have good systems to follow up on ordered test results, "the thing that’s been a real vulnerability is when the patient is sent for a test and never shows up. There are a number of organizations that have been innovating in this area and driving down their malpractice claims." In most of these interventions, the electronic order entry system sends a notification to the ordering provider that the patient has not completed a test that was ordered.
In a 2012 analysis of 56 cases alleging delayed diagnosis of breast or colon cancer, researchers found that virtually all of the cases involved one or more cognitive errors, such as a provider making the wrong decision about what test to order or what to do about the results.2
"The typical mistake that we see involves the incorrect assumption that since a single test was normal, no additional follow-up is needed," says Eric Poon, MD, MPH, the study’s lead author and vice president and chief medical information officer at Boston Medical Center. Poon is associate professor of medicine at Boston University School of Medicine.
About half of the cases involved logistical errors. "The clinician knew what the right plan was, but somehow the execution of the plan fell through the cracks," says Poon. The researchers recommend the following:
• Improvement of the effectiveness and use of clinical guidelines in the selection of diagnostic strategy, both during office visits and when interpreting test results.
"If guidelines can be made available as a point of care when clinicians are making decisions, they are less likely to make these errors," says Poon.
• Tools to facilitate communication and to ensure that follow-up visits occur.
"Making test results and the treatment plan available to patients online may be helpful. But we should caution ourselves to make sure we don’t rely on that as a failsafe," says Poon.
The best approach is for providers to communicate the treatment plan to the best of their ability when the patient is sitting in front of them, he says, and confirm the patient’s understanding of the plan. "We need to document those plans as much as we can in the medical record, so if the patient comes back at another time, another provider might have the opportunity to remind them," he adds.
- Weingart SN, Saadeh MG, Simchowitz B, et al. Process of care failures in breast cancer diagnosis. J Gen Intern Med 2009; 24(6):702-709.
- Poon EG, Kachalia A, Puopolo AL, et al. Cognitive errors and logistical breakdowns contributing to missed and delayed diagnoses of breast and colorectal cancers: a process analysis of closed malpractice claims. J Gen Intern Med. 2012; 27(11):1416-1423. F