Overlooked abnormal reports: an opportunity for practice improvement

The information management burden of clinical practice grows perpetually. As dispiriting as that may be at times, physicians have a legal, ethical, and professional obligation to safely and effectively manage information, which must include standardized practice procedures to minimize the risk of missing a critical, abnormal report. Whether paper or electronic, physicians must carefully review and sign off on all incoming reports.

Over the past few years, the Inquiry Committee has investigated several complaints of physicians signing off on and filing abnormal breast cancer screening and/or diagnostic reports without acting on the advice provided. In each case, the committee’s investigation determined that physicians who were found to meet expected standards otherwise had inadvertently initialed or electronically signed and submitted the reports as requiring no further action. Given the large number of reports typically reviewed in a sitting, it is easy to see how one could be missed. These errors have occurred with both paper and electronic records. The task requires diligence and focus.

The patient safety literature uses the “Swiss Cheese Model” to illustrate how a series of errors can align to cause a truly adverse event. Often, for example, a sign-off error is detected by clinic staff or a colleague, or when the patient calls to inquire about results and harm is prevented. But many patients came of age when medical offices commonly utilized a “no news is good news” system and discouraged patients from calling. Physicians cannot rely on patients to call unless they direct them to.

While the Inquiry Committee acknowledges that it may take a whole team to turn a physician error into an adverse outcome, careful attention when reviewing reports is considered a foundational standard of care. Physicians play a major role in the process and are held accountable for their actions. Sufficient time should be set aside every day to review incoming results, and physicians must be deliberate in managing this mundane-but-high-stakes task in a way that minimizes distraction.

Failing to take appropriate action on receipt of a critical report may be considered unprofessional conduct. If the report was actively signed off by the physician, there is really no defense. Not only are physicians invariably personally devastated when they make such errors, they may also face a formal reprimand, pursuant to section 36(1)(c) of the Health Professions Act. The consequences of avoidable diagnostic delay for patients often cannot be definitively determined but, in the event of a bad outcome, those affected are left to wonder.

The College urges all physicians to evaluate the manner in which incoming results are managed in their office, and to include staff in the conversation. Consider involving patients by having them call in for selected results such as breast imaging, fecal screening, and cervical cytology. The expanded use of portals to allow patients to check their own results might also be an option. Flaws in a process or system have the potential to cause harm to patients.