Fumbled Handoffs: One Dropped Ball after Another

Quality Grand Rounds is a series of articles and companion conferences designed to explore a range of quality issues and medical errors. Presenting actual cases drawn from institutions around the United States, the articles integrate traditional medical case histories with results of root-cause analyses and, where appropriate, anonymous interviews with the involved patients, physicians, nurses, and risk managers. Cases do not come from the discussants' home institutions. Summary of the Case Robert Woods (a pseudonym), a 70-year-old man with a history of spinal stenosis, chronic alcohol abuse, and vitamin B 12 deficiency, was admitted to the medical service of an urban teaching hospital for evaluation of generalized weakness and poor appetite. A single, undetected oversight multiplied and compounded over time; as a result, Mr. Woods's serious illness remained undiagnosed, with fatal consequence. The Case The patient presented to an outpatient satellite clinic associated with an urban teaching hospital, reporting several weeks of weight loss and cough. A chest radiograph revealed a dense infiltrate in the posterior segment of the right upper lung, extensive fibronodular disease, and decreased volume, which were not seen on a previous chest radiograph. The radiologic impression was: Right upper lobe pneumonia. It is unclear whether this is a simple pneumonia or a postobstructive pneumonia secondary to a lung mass. Recommend a CT [computed tomography] scan for further evaluation. Mr. Woods received an oral antibiotic for presumed bacterial pneumonia and was scheduled for a lung CT scan. Mr. Woods returned 3 weeks later for the CT, which revealed cavitary pneumonia predominantly involving the right upper lobe, with scattered areas of spread to the right lower lobe and left lung. No evidence suggested pleural effusion, empyema, or a predisposing obstructive lesion. The radiologist wrote: The differential diagnosis is necrotizing bacterial pneumonia; TB [tuberculosis] would also be a consideration. Mr. Woods was prescribed another course of oral antibiotics. Several weeks after his CT scan, Mr. Woods returned to the satellite clinic and noted that his cough had improved. While fortuitous that the patient returned for a follow-up chest CT 3 weeks after initial antibiotic treatment, the worrisome CT findings were probably not communicated to the ordering physician. This abnormal CT result (particularly the tuberculosis aspect) merited direct communication, such as a telephone call, from the radiologist to the ordering physician. As it transpired, the patient was merely prescribed another course of antibiotics and did not undergo a work-up for tuberculosis. Mr. Woods's experience to this point highlights a critical safety issue: the inability or failure of an ordering physician to track and react to test results in a timely manner. Failure to follow up on abnormal diagnostic test results is a critical weakness in patient safety, particularly in outpatient care (1). One study found that 75% of physicians did not routinely notify patients of normal test results (2) and that up to 33% of physicians did not even always notify patients about abnormal test results. In addition, less than 25% of physicians had a reliable method for identifying patients who were overdue for follow-up. Several studies (2-5) underscore the ongoing need to address this quality gap. For example, 31% of women with abnormal mammograms do not receive follow-up care consistent with well-established guidelines (4), while up to 33% of women with abnormal Papanicolaou (Pap) smears are lost to follow-up (5). A recent analysis by a large malpractice insurer showed that about 25% of diagnosis-related malpractice cases were due to failures in follow-up (6). Other studies reveal that communication breakdowns are causative factors in 80% of malpractice lawsuits (7). Lawsuits alleging failure to communicate radiology results are particularly prevalent and are becoming more so (8). In nearly 60% of these suits, the referring physician was not directly contacted about urgent or clinically significant unexpected findings (9), similar to the scenario in Mr. Woods's case. A recent study shows that delays in reviewing test results are common, and many physicians are not satisfied with how they manage test results (10). Many reasons potentially underlie this dissatisfaction. First, the volume of data to be reviewed is large; a typical primary care provider may review up to 800 results from chemistry and hematology reports, 40 radiology reports, and 12 pathology reports per week (11). Second, test results in the outpatient setting become available at times ranging from an hour to weeks after the tests are ordered, making it easy for physicians to forget to look for their results. Third, paper-based test-reporting systems are subject to delivery delays and misfiling. Fourth, specialists in testing areas often do not have adequate clinical information about why the test was ordered and do not have clear criteria for which results require a telephone call. For example, a recent study found little agreement between pathologists and clinicians about the types of results that constitute a critical value and the degree of urgency for contacting a physician (12). Even assuming consensus as to the latter, often no information is noted about the preferred and absolutely fail-safe communication mode (for example, how to proceed when a page is not answered or when a physician is out of town). The Case, Continued One month after the lung CT was performed, Mr. Woods presented to the emergency department of the teaching hospital, reporting generalized weakness, fatigue, and decreased oral intake. The patient did not have any pulmonary symptoms at admission and reported no fever or chills. Unfortunately, his ability to relate relevant information was poor, and little further history was obtained. His vital signs at this time were normal, and his lung examination was notable primarily for scattered rhonchi. A chest radiograph again revealed evidence of previous granulomatous disease and a persistent active cavitary process that the radiologists characterized as probable active tuberculosis, with development of increased infiltrates in the right middle lobe and left lung. Mr. Woods was admitted to the medical service by a night-float resident, who (inexplicably) entered the following note in the medical chart: Chest radiographunremarkable. In the morning, the patient and 4 other new night-float admissions were handed over to a new team. This particular medical team was very busy, and the senior medical resident was switching teams the next day. Although this resident's practice was usually to scan old radiology records to inform himself fully about his patients, in this instance he did not do so because he was pressed for time, and the patient had no pulmonary symptoms. Furthermore, the resident rationalized that the new resident joining the team the next day would more thoroughly investigate Mr. Woods's history. Thus, the team caring for Mr. Woods worked under the assumption that Mr. Woods's chest radiograph was normal. Although Mr. Woods's original chest radiograph and CT scan reports were still available in the hospital's computerized record, they were never reviewed. Since the day after the patient was admitted was the medical resident switch day, Mr. Woods was signed out as a patient admitted for anemia and progressive weakness. Because his vital signs remained stable during his hospitalization and he had no pulmonary symptoms, a chest radiograph was not repeated. A major issue in this case is whether the emergency department could obtain the relevant outpatient records (including the CT scan result), which would have pointed them to a diagnosis of tuberculosis. It is unclear whether the emergency department routinely contacted outpatient caregivers to obtain relevant clinical information; if not, this is, unfortunately, not unusual. One study found that information was absent in almost 33% of emergency department visits (13), consisting primarily of missing medical history and laboratory test results, and that in half of the cases the information was essential to patient care. Systems such as electronic medical records (linking the inpatient and outpatient settings) or patient-owned medical records are being evaluated as tools to improve this communication gap. Unfortunately, the high cost of these systems has led to a slow rate of adoption. The chest radiograph on admission to the hospital was reported as prior granulomatous disease and probable active tuberculosis. Again, a highly clinically significant abnormal finding that warranted direct communication from the radiologist to the medical team was not communicated. Obviously, the ordering physician is responsible for obtaining the results of any tests ordered. The resident probably read the radiograph himself, which often occurs during off hours. However, a key feature of a fail-safe system is a back-up systemplanned redundancy. The radiology attending could have been the designated back-up and, in this case, might have caught the resident's error by directly communicating the result. Another major issue is the error made by the night-float resident in documenting a normal chest radiograph. The reason for this error is unclear, although he may have looked at the patient's old radiographs instead of the new ones. If so, this would be a classic case of human error (14), probably related to human factors such as fatigue, workload, and interruptions. Digital imaging can help sift through the confusion that may be caused by the existence of several hard copy radiographs in reading rooms, any of which could be inadvertently interchanged. Digitized images also can decrease the misreading of dates, since the dates are usually sorted chronologically. However, technology can also introduce new errors (15), such as accidentally selecting