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Diagnostic tips


Reducing medical-legal difficulties

Follow-up of investigations


Male physician looking at records

Case: No news is good news
Back of female patient undergoing mammogram

Background

A 55-year-old woman has a screening mammogram as a component of her annual health exam. The radiologist dictates the report as "lesion in left upper quadrant suspicious for malignancy, recommend needle biopsy."

The report is transcribed but not sent to the referring physician.

The patient assumes no news is good news and does not follow up.

The radiologist assumes the report has been sent to the family physician.

Outcome

One year later the patient presents to her family physician with a palpable breast lump.

Investigation, including biopsy confirms an invasive carcinoma with lymph node involvement.

Think about it

  • How might this delay in diagnosis have been prevented?
  • Who do you think might be accountable for the follow-up of the mammogram?

Lessons learned

  • The courts have ruled that when ordering a test the physician must be satisfied there are systems in place, both in the office and the laboratory/facility, to reasonably ensure the results of the test are received in a timely manner. In this case, both the family physician and the diagnostic imaging centre have responsibility for following up on the mammogram.
  • The more serious the implications of an abnormal result, the more promptly the result should be delivered to the referring physician. The protocol or system must also provide for appropriate steps to be taken to report the results to the patient and to arrange necessary follow up.
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Case: Failed follow-up of a biopsy
Incision of mole

Background

A family medicine resident excises and sends to pathology an irritated nevus on the thigh of a 27-year-old teacher in the ambulatory care clinic.

No follow-up appointment is arranged as the resident is not worried about the diagnosis.

Outcome

One year later the patient returns to the clinic because he has developed a black spot in the scar of the previous biopsy.

The supervising physician discovers the previous biopsy report, filed at the back of the patient's medical record, indicating a malignant melanoma and recommending a wide excision.

Think about it

  • Could this happen to one of your hospital patients?
  • When dictating the patient's discharge summary do you confirm that all investigation reports have returned, been reviewed and acted upon?

Lessons learned

  • Lab and diagnostic imaging tests are of no value if they are not performed, reported, received, read, and acted upon.
  • Is there an effective tracking system in place in your practice or facility to review diagnostic tests in a timely fashion?
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There are many possible reasons for the failure to follow up on investigations.

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The Swiss Cheese model

Safeguards in the system of care are like slices of cheese with holes representing possible failure points. Click on each slice to understand the risks in this process.

Patient factors

The investigation may not be done because the patient:

  • is too busy
  • does not appreciate the need for the investigation
  • loses the requisition

For more information on the Swiss Cheese model see what is "systems thinking".

Case: Radiology department chief seeks advice
Female physician on telephone and CMPA logo

Background

The chief of a hospital radiology lab calls the CMPA for advice regarding the handling of critically abnormal investigations which have been ordered by walk-in clinic physicians who are not available to receive the results, particularly outside regular office hours.

There is no mechanism in place in these walk-in clinics for urgent matters to be reported to a responsible physician. The problem is further compounded by the fact that patient contact information is often inaccurate on requisitions.

Think about it

  • What advice would you give to the chief of radiology?
  • Do you think urgent critical results may need to be communicated directly to the patient by the radiologist in this circumstance?

Suggestions

CMPA advice is based on court decisions:
  • While the report to patients is usually the duty of the ordering physician, the laboratory or facility may be expected to take necessary steps to notify patients in cases of emergency when the ordering physician is not available.
  • Reasonable efforts should be made to contact the patients. It is recommended that the chief discuss with hospital authorities the need for revised procedures to ensure that patient contact information is accurate.
The chief of radiology also plans to contact the clinics to discuss the issue and find a suitable solution.
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