Everyone’s worst nightmare is identifying a possible cancer yet the patient not being made aware and getting prompt attention when the cancer might be at a treatable stage. Lots of examples are available:
How can we prevent these sorts of disasters? Communication at multiple levels is critical (lab/hospital, physician/practice/outpatient clinic, patient/family). And you need systems to help you.
At the hospital level, several things can be done. First is putting in place a system to ensure notification of practitioners of any unexpected findings (eg. a suspicious lesion seen on a radiograph ordered for other purposes). It is not uncommon these days for patients to be discharged from the hospital before the final radiology report hits the chart. So one must assume that such a finding could be overlooked, even if the hospital sends copies of all reports to the physician office as well. Such a system requires setting up a log (paper or electronic) to confirm that the practitioner was contacted by the radiologist to notify him/her of the suspicious finding. The “case” is not closed until that conversation has taken place. There are examples in the literature of successful implementation of such systems.
Also, the hospital discharge summary should always include a section for “tests done but official reports pending” so that the practitioner following up the patient is alerted to the fact not all reports were final at discharge.
At the physician/practice level, you need a system to track results of all tests ordered. A paper-based tracking system is theoretically possible but not practical for most practices. Technology provides the best solutions. However, you don’t need an expensive electronic medical record. A simple Excel spreadsheet or Access database will do. Simply set it up with the patient name (and a second identifier so you don’t mistakenly mix up 2 patients!) and a column/field for tests pending and one for date ordered. You could also have a column for the date you contacted the patient with the results. You simply then sort your list each day by the “tests pending” field so you can follow up on reports that should have been received but have not yet been received. You then remove the test from the test result pending field as the result comes in. You can have a similar system on your handheld PDA but make sure you take appropriate measures to safeguard patient health information.
Also, when the paper reports come in to the office, they should not be filed until the practitioner has indicated (usually by initialing the report) that he/she has read the report.
At both the hospital and practice levels, make sure you perform periodic audits to ensure that the process you set up is indeed effective.
Lastly, as a patient, never assume that no news is good news. Any time you have a test done, ask your physician when and how the results will be communicated to you. And if you have not heard the results within a reasonable period of time, contact your physician to find out the result.
Update: See our February 12, 2008 Patient Safety Tip of the Week “More on Tracking Test Results” and our October 13, 2009 Patient Safety Tip of the Week “Slipping Through the Cracks” and our July 2009 What’s New in the Patient Safety World column “Failure to Inform Patients of Clinically Significant Outpatient Test Results” for much more on the issue of following up on tests, consults, etc.