Originally published December 2012
Irrespective of the clinical setting, diagnosis can be improved when test results are communicated in a timely and reliable manner to the clinician who can provide follow-up care.
In a hospital setting, managing test results is not the sole responsibility of the physician who orders the test. The hospital, laboratories, and other healthcare professionals also play a role in communicating or following up on test results. All members of the team are accountable for their respective role, whether it is ordering a test, conducting it, communicating results, or ensuring clinical follow-up.
In the management of test results, hospitals have a responsibility to provide patients and health professionals with a system that is reasonable, safe, and reliable. The system should support the effective coordination of care between providers, patients, and the hospital, and should clearly define the accountabilities of each. As most patients will receive care from multiple providers in a number of departments, this coordination becomes paramount.
Physicians rely on a hospital's reporting system to fulfill their duties to patients. In an effective system, reports are readily available, and incomplete tests are easily identified so clinicians can decide if they must contact the patient. Abnormal results are flagged and brought to the attention of the physician ordering the test, and, failing this, to the patients involved. A tracking mechanism which confirms patients have been informed of abnormal test results and appropriate follow-up care has been initiated is an important feature of an effective system.
Physicians ordering investigative tests are responsible for the timely and appropriate follow-up of results. In a hospital setting, physicians must be reasonably satisfied that the system will provide them with test results in a timely manner, allowing them to communicate the results to their patients and arrange the necessary follow-up care. Physicians who are aware of any deficiencies in the system should report these in writing to the appropriate authorities within the hospital. Colleges have stated and legal judgements have emphasized that physicians are expected to follow up on test results in a timely manner. It is important that clinicians follow up closely when ordering tests for patients with unstable, urgent, and potentially life-threatening illnesses, and those with serious symptoms or signs.
Physician's accountabilities for test results are likely outlined in hospital procedures. Similarly, the responsibilities of other health professionals in the management of test results should also be outlined in these procedures. Knowing these and the role of each provider will promote the effectiveness of the system and contribute to safer care.
Findings from CMPA case files
The CMPA reviewed its medico-legal case files that closed between 2006 and 2011 where the management of test results and diagnostic imaging reports in a hospital setting was considered to have contributed to a delay in diagnosis. Of the 231cases reviewed, 62% were legal cases, 30% were complaints to medical regulatory authorities (Colleges), and 8% were complaints to hospitals.
The majority of missed or delayed diagnoses were related to lung cancer; cardiovascular disease, often a myocardial infarction; or spinal injury, often at the cervical level. In these cases the patients' clinical outcomes were frequently serious, including death.
In 76% of all the cases reviewed, there was an unfavourable medico-legal outcome for physicians. The legal cases had an unusually high rate of settlements or judgments for the plaintiff compared to the general CMPA experience. The College complaint cases had a high rate of physicians being counselled or cautioned.
Of the physicians involved in ordering diagnostic tests, family and emergency physicians followed by obstetricians and surgeons were the groups most frequently identified in the cases reviewed.
Main issues identified
The review of these case files identified 5 main issues:
- procedures for managing test results were inadequate or absent
- communication between healthcare professionals regarding test results was lacking
- investigative test records, reports, or results were not read or there was a delay in reading them
- follow-up on test results was deficient
- specific diagnostic tests or procedures were delayed or not performed
In the cases reviewed, some issues were identified as occurring less frequently, including the loss or misplacing of reports or test results.
The following sample cases illustrate some of these problem areas.
A patient was being followed in a hospital's outpatient clinic for an abnormal thoracic-computed tomography (CT) scan.
She had a follow-up appointment and the respirologist had provided a note to the office staff that it was urgent. The clinic cancelled the appointment, but failed to provide an alternate date. As the respirologist's note had been discarded, the staff members were now unaware that the follow-up appointment was urgent. The patient was not seen again. A year later she experienced persistent cough and right shoulder pain and was diagnosed by her family physician with adenocarcinoma of the lung with metastases. A legal action was launched, and experts in the case were critical of the respirologist's and hospital clinic's lack of procedures to ensure that patients receive appropriate follow-up. The patient received a settlement. The payment of that settlement was shared by the CMPA (on behalf of the member) and the hospital.
A trauma resident ordered a knee X-ray for a patient involved in a motor vehicle collision who was complaining of knee pain.
The resident wrote on the chart that he would review the X-ray. The patient's care was then transferred to the orthopaedic service and ultimately no one followed up on the X-ray, which showed a fracture. The patient was discharged. Four months later the patient demonstrated a serious knee injury requiring an open surgical procedure. Post-operatively the patient developed a wound infection. Left with chronic knee pain, the patient was later treated for anxiety and depression. A legal action ensued alleging the diagnosis of the knee fracture was delayed. Experts in the case identified the contributing factors as the lack of communication between staff and the lack of a procedure to ensure X-rays were followed up. On behalf of the member-resident, the CMPA contributed to a settlement to the patient.
A patient had his gallbladder removed and during the surgery the surgeon noted significant inflammation in an area surrounding the organ.
Following the surgery, the patient failed to follow up with the surgeon as instructed. The patient, however, visited his family physician three weeks after the surgery for an annual assessment. At that time the doctor did not have any consult reports. Nine months later, the patient, complaining of abdominal pain, again visited his family physician. An ultrasound revealed a large mass on the patient's liver. The family physician requested the gallbladder pathology report from the surgeon. Realizing that the report had never been received, the surgeon's office obtained it from the hospital. The report showed the patient had an aggressive form of cancer. The pathologist had signed off on the report two weeks after the patient's gallbladder surgery, which meant it was available electronically via a hospital information system, and a hard copy should have been mailed to the surgeon as well. It was never determined why the report was not received by the surgeon's office. About 2 years post-surgery the patient died. A legal action was launched naming the two physicians and the hospital. The action against the physicians was withdrawn, and the matter was resolved between the plaintiff and the hospital.
Contributing to a stronger system
Within the hospital setting, it is the institution's responsibility to design and maintain a reliable system to manage test results and diagnostic reports. An effective system generally clarifies who should receive the results; who should receive the results when the ordering provider is not available; how those results are communicated; what results require timely notification; how quickly the results should be communicated; how to document the results in the patient record; how and who informs the patient of the results. While dependant on the hospital system, physicians have a duty to their patients which includes appropriate follow up of test results.
Effective communication between providers
A system that supports effective and clear communication between providers advances the timely follow up of tests and diagnostic reports. In a hospital setting, where multiple providers in various locations are caring for patients, effective communication of test results takes on added importance.
The CMPA case files demonstrate that the communication process often breaks down when a patient is transferred between providers or departments in the hospital. An effective system promotes the transfer of information between providers, across hospital departments, and from the hospital to other settings such as clinics. For example, physicians receiving abnormal test results should consider which healthcare professionals need to be advised of the results and how best to communicate these. Communication with these other professionals should be clear, comprehensive, and timely. More detailed information on communicating with other healthcare professionals and using communication tools can be found in the CMPA article, "Strengthening inter-professional communication."
An effective system for managing test results will also ensure that when patients leave the hospital, the necessary information will be transferred from the hospital to the community-based healthcare setting. Patients may be discharged from hospital with test results still pending. Discharge instructions to the patient and the discharge summary to the family physician are standard means of sharing information. A timely, accurate, and complete summary from hospital-based physicians gives the subsequent treating physician the patient's full medical condition, including any pending test results and the necessary follow-up care. Information on communicating with the patient on discharge instructions can be found in the article, "Discharging patients following day surgery."
Documentation in the medical record
Good documentation in the medical record can strengthen the hospital's system for managing test results as it is a primary communication tool between physicians and other healthcare providers. By documenting in the record the reasons for ordering a test, any differential diagnoses, and the test results, physicians give a clear picture of the patient's treatment and any follow-up care that is required. More information on good documentation in the medical record can be found in the article "Why good documentation matters."
Strategies to improve follow-up of investigative test results in a hospital setting
The following may assist physicians in fulfilling their role in managing investigative and diagnostic test results in a hospital setting.
Be familiar with your hospital's system for managing test results. Physicians should be familiar with the hospital procedures and the system they are relying on to manage test results, particularly the procedures notifying them or the patient of abnormal results. They should be clear on their role and responsibilities within that system.
Advise appropriate personnel of system deficiencies. Physicians who are aware of inefficiencies or deficiencies in the system for managing test results should communicate these to the appropriate hospital authorities, preferably in writing. Keeping a copy of the correspondence is prudent. Irrespective of any system deficiencies, it is incumbent on physicians to ensure the timely and appropriate follow-up of results.
Identify high-risk patients and clinically significant test results. Physicians should take added precautions when caring for a patient in urgent situations or who appears at higher risk of receiving a clinically significant result.
Communicate effectively. Physicians should be aware that good communication between hospital departments and between providers is essential to an effective system for managing diagnostic test results. When patients are discharged from hospital, good communication must also extend to the community care setting.
Engage patients in their own care. Physicians should discuss with their patients why an investigative test has been ordered for them. Patients can take more responsibility for their own care if they understand why the recommended testing is important to their clinical situation.1 Physicians should refrain from telling patients that abnormal test results will be communicated to them, while normal results will not. Abnormal and normal test results can go astray. Physicians should also consider encouraging patients to enquire about their test results.
Contact the CMPA
Members with questions on the follow-up of investigations in hospitals and other institutions can contact the CMPA for advice and speak with one of the Association's medical officers. The medical officers can be reached by phone at 1-800-267-6522 or by submitting a medico-legal assistance/web form.
- Wahls, Terry, "Diagnostic errors and abnormal diagnostic tests lost to follow-up, A source of needless waste and delay to treatment," Journal of Ambulatory Care Management, (2007) Vol. 30, no. 4, p341.