Delayed Diagnosis

December 2015

Timely lab test results are critical to patient care, and this month, we are reviewing a case where a physician and patient did not receive the lab test results they requested, leading to a delay in the patient’s diagnosis and treatment.  We are working on system fixes and staff education to prevent this kind of error from repeating itself.

What can you as a patient do to ensure this doesn’t happen to you? Please partner with us in your care – call your care provider’s office if you do not receive your test results within the time frame that you were told. 

Thanks for reading.

AllenSignature

Allen Kachalia, MD, JD
Chief Quality Officer, Brigham and Women’s Hospital


 

What Happened
A patient had multiple labs drawn during a specialist appointment at BWH. The patient and physician received some of the test results, but not for the test that detects thyroid problems (thyroid stimulating hormone, or TSH, level).

Two months later, the patient returned to BWH to see her primary care provider (PCP). At this point, she had many symptoms of hyperthyroidism, including fatigue, weight loss, restlessness, fullness in the neck, an abnormally rapid heart rate and elevated blood pressure.

The PCP noticed that the lab results drawn two months prior showed low TSH. New labs were drawn, and the PCP prescribed medication to treat the hyperthyroidism. The PCP also filed a safety report to notify Patient Safety that the lab results were not received.

Although there was a delay in the diagnosis and treatment, the patient fortunately did not suffer any long-term complications. However, the delay prompted an additional office visit because symptoms of her hyperthyroidism were progressing.

What Went Wrong
Upon investigation, we learned that a lab technician had accidentally entered the wrong provider ID code into the system, so the test result confirming low TSH never reached the specialist’s LMR Results Manager (the system for providers to track test results). Unaware of the abnormal results, the specialist did not follow up with the patient. The abnormal TSH value was not a critical test result that would have initiated a phone call from the lab to the provider to confirm receipt.

What We Are Doing

  • Partners eCare: BWH recently launched a new electronic health record system and is working to optimize the system to help prevent laboratory errors and gaps in care and communication.
  • Education: The lab technician was informed of the error, and staff were educated and re-trained to prevent future errors while using the computer system. Staff were also reminded of the policy that requires a double-check of lab test requisitions.
  • Patient education: Physicians and other health care personnel should educate patients about the importance of receiving all lab results and when and how to expect them. Care providers should encourage patients to call if they do not receive their results within the expected timeframe. View a new patient safety brochure that addresses this and other important topics for patients.
  • Executive Walk-rounds: Senior leaders and patient safety leaders visited with staff as part of walk-rounds, an open discussion of safety issues and concerns. BWH is committed to communicating about errors to ensure all staff are informed about what happened so they can prevent mistakes from reoccurring.

Just Culture Corner: Human Error Happens
BWH is committed to adopting the principles of a Just Culture and creating an environment where we feel safe speaking up and supported after making mistakes. This delayed test results case details a combination of system error and human error, which, according to Just Culture principle, warrants consoling and coaching, rather than punishment. Punitive action is only warranted if staff act with reckless behavior and knowingly cause unjustifiable harm.

The lab technician in this instance did not behave recklessly. The technician had no intention of harming the patient. Whether this was due to environmental distractions, a simple cognitive lapse or something else, it is reasonable to believe that entering the wrong ordering provider code was human error. All lab staff were educated on the importance of double-checking lab test requisitions and re-trained to prevent similar errors.The other component of this error involves an ordering system that allowed the order to be entered incorrectly and go unnoticed. The Partners eCare Critical Test Result Task Force was formed to improve the process for ordering, reporting and reviewing labs.People are not perfect, and even our computers and systems are not without fault.

In Just Culture, the key is to train and prevent, rather than blame and punish. Through this model, health care providers can feel free to speak up, and through training and education, prevent errors from happening.Learn more.

4 thoughts on “Delayed Diagnosis

  1. J Hubbard

    You don’t seem to mention that the physician who ordered the lab also did not go looking for it. Follow through on the physician part is even more important.

    1. Karen Fiumara

      Thank you for your comment. While follow-up is certainly important, it is our goal to create systems that do not rely on an individual’s memory and protect against human error. The system should prompt our providers and flag anything noteworthy to help us enhance patient safety.

  2. Bill Donaldson

    First major kudos for the exceptional transparency. This is the mark of a outstanding leadership and demonstrates a culture of quality.

    I question the root cause analysis in the write up. While you’re 100% right not to blame the lab tech – thank goodness – and demonstrates the right cultural signals. Shouldn’t there be a check, in the system, to prevent entering the wrong provider id code. The tech shouldn’t be able to enter the id and it should be prepopulated when the PCP requested the test. This calls for poke yoke not statement the computer system is not perfect.

    Also, there should be a closed loop when the request was entered. An alarm should have triggered when the results was not returned to the PCP after a predetermined period.

    These details might have been omitted for clarity and brevity in the write up. If not suggest looking at Lean healthcare for additional tools in your quality quiver.

    1. Karen Fiumara, Director, Patient Safety BWH

      Thank you for your wonderfully insightful comments. We agree that this calls for Poka-yoke (mistake proofing).

      We have recently implemented a new electronic health record system and are working to optimize the system to “mistake proof” against these types of events. We believe this will be possible through the implementation of a closed loop communication system. Our goal is to set up a system in which an order for a lab test would be electronically transmitted (without the need for a technician to transcribe the provider information) and the result would be electronically transmitted back to the provider. Ideally, if the result is never sent, there should be a “signal” to the provider that a test was “sent” but a result was not returned.” This would provide an additional fail-safe.

      Thank you again for your thoughts. If other readers have suggestions regarding how this works at other facilities, please feel free to comment. We would love to use this blog as an opportunity to share best practices.

      Best, Karen

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