One of the most egregious errors in healthcare is failure to follow up on significant test results. These may be results of bloodwork, other laboratory tests, pathology studies, imaging studies, and other diagnostic tests.
In our October 13, 2009 Patient Safety Tip of the Week “Slipping Through the Cracks” we highlighted a study that showed almost 8% of patients with critical imaging results had not received appropriate follow-up within 4 weeks (Singh 2009).
Researchers from that same group have now developed and validated a “trigger” tool to detect such delays in treatment for patients having abnormal results of lung imaging studies (Murphy 2015). The researchers developed an electronic health record (EHR) algorithm based upon reports of chest CT images and/or conventional chest radiography that had been read as “suspicious for malignancy”. The algorithm excluded patients in whom appropriate and timely follow up had taken place (such as a pulmonary visit) or cases in which no follow up was necessary (eg. patients with terminal illness). The trigger algorithm was retrospectively applied to the records of over 89,000 patients. Of 538 records with an imaging report that was flagged as suspicious for malignancy, 131 were identified by the trigger as being high risk for delayed diagnostic evaluation. Manual chart reviews were then done and confirmed a true absence of follow-up in 75 cases, of which four received a diagnosis of primary lung cancer within the subsequent 2 years. The positive predictive value (PPV) for the trigger was thus 57.3% for detecting evaluation delays. The researchers now plan to apply the trigger tool prospectively.
We clearly need ways to ensure that patients with significant imaging (or lab) findings have had appropriate follow-up. Phone calls and emails may be cumbersome if they need to be made on all patients with such findings. However, using trigger tools such as the one described here can filter down the list of cases needing such phone calls or email follow-ups can go a long way to ensuring no one “falls through the cracks”.
See also our other columns on communicating significant results:
Singh H, Thomas EJ, Mani S, et al. Timely Follow-up of Abnormal Diagnostic Imaging Test Results in an Outpatient Setting. Arch Intern Med. 2009; 169(17): 1578-1586
Murphy DR, Thomas EJ, Meyer AND, Singh H. Development and Validation of Electronic Health Record–based Triggers to Detect Delays in Follow-up of Abnormal Lung Imaging Findings. Radiology 2015; published ahead of print May 11, 2015
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