Jennifer R.S. Gordon, BS; Terry Wahls, MD, MBA; Ruth C. Carlos, MD, MS; Iraklis I. Pipinos, MD; Gary E. Rosenthal, MD; Peter Cram, MD, MBA
Gordon JR, Wahls T, Carlos RC, Pipinos II, Rosenthal GE, Cram P. Failure to Recognize Newly Identified Aortic Dilations in a Health Care System With an Advanced Electronic Medical Record. Ann Intern Med. 2009;151:21-27. doi: 10.7326/0003-4819-151-1-200907070-00005
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Published: Ann Intern Med. 2009;151(1):21-27.
Concern is growing about missed test results, but data assessing their effect on patient safety are limited.
To examine the frequency with which computed tomography (CT)â€“documented dilations of the abdominal aorta are accompanied by evidence in the electronic medical record (EMR) that a clinician recognized the abnormality.
Retrospective cohort study.
2 hospitals in the Veterans Affairs Health Care System.
Patients with new dilations of the abdominal aorta detected on CT performed in 2003.
Radiology report and EMR evidence that the radiologist notified the clinical service, aneurysm size, and interval between CT and EMR recognition.
Computed tomography scans of 4112 patients were reviewed and 440 (11%) aortic dilations were identified, of which 91 were new findings. Radiologists directly notified clinical teams about 5 (5%) new dilations. Clinical teams did not record in the EMR recognition of 53 of 91 (58%) dilations within 3 months of the CT, and 9% of these dilations were 5.5 cm or larger. The median time to recognition of aneurysm in the EMR was 237 days, and no EMR documentation existed for 16 abnormalities (29% of surviving patients) during a mean follow-up of 3.2 years. No evidence indicated that any of the aneurysms ruptured or that patient deaths resulted from the delayed follow-up.
Clinicians may have recognized some aneurysms but did not document them in the EMR.
Clinicians neglect to note a substantial proportion of new aortic dilations in the EMR. The findings highlight the need for better strategies to ensure documentation of follow-up of tests.
National Institutes of Health.
Studies estimate that clinicians may not recognize 3% to 30% of abnormal test results in a timely manner, leading to potential malpractice suits, treatment delays, and patient harm.
This study examined the electronic health records of 91 patients with newly detected aortic dilations on computed tomography and found documentation in the record that the clinical service was aware of the finding for only 42% within 3 months and 66% within 4 years of the scan. No evidence existed of patient harm associated with failure to document these findings.
Strategies are needed to ensure that clinicians have recognized and documented abnormal test results.
CT = computed tomography.
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Emergency Medicine, Hospital Medicine, Prevention/Screening.
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