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  • Mark L. Graber, MD
  • President, Society to Improve Diagnosis in Medicine
graber

Physicians tend to be overly trusting of diagnostic testing results. They generally believe that tests are definitive, and tend to discount the reality that each test has its limitations in sensitivity and specificity.

We should incorporate test results in our decisions based on Bayesian analysis, but few physicians actually take this approach, and few tests results actually include the data on test characteristics that would allow these calculations.

Compounding the problem, few medical schools include formal training on how to appropriately interpret test results, and where to find the best information on test ordering and result interpretation.

Another factor here is the growing distance between the clinicians who are ordering tests and the services providing them: the clinical laboratory and the radiology department. The results are typically just passed back and forth, never really discussed.

(President, Society to Improve Diagnosis in Medicine)

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Testing and Results Processing

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Testing and Results Processing

Related to: Diagnosis, Emergency Medicine, Primary Care, Nursing, Obstetrics, Other Specialties, Surgery

biopsywebAccording to CRICO’s 2014 CBS Benchmarking Report: Malpractice Risks in the Diagnostic Process, on average, a third of patients with a health complaint will undergo diagnostic testing. The ordering physicians and patients  rely on the proper performance, interpretation, and transmittal of  the results to reach diagnostic certainty. More than one in four of the malpractice cases in this study involved breakdowns in one or more of these testing-related steps in the diagnostic process.

 

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Sending patients (or specimens) for testing is fraught with opportunities for something to go wrong. Staff, and the systems they use, have to make certain that the right patient gets the right test and safeguard that specimens are properly handled. Specialists who are, essentially, expected to be infallible in their interpretation and communication skills, need training and protocols that minimize misreads or misdirected results. Primary care providers need to ensure that their interpretations of the results align with the specialists’, and that they comprehend the full extent of the report. Together, the providers ordering and performing diagnostic tests have to guarantee that the reasons for testing are clearly expressed and that results are timely, unambiguous, and communicated in a logical format via the proper channels.

Misinterpretation of diagnostic studies is among the most common factors in failure to diagnose cases from an ambulatory setting. Hindsight provides malpractice plaintiffs with knowledge of precisely what to look for in test or lab results—or in a consultation report—leaving defendant physicians having to answer “Why didn’t you see this then?” Protocols for reducing the types of errors that most often involve test results in malpractice cases alleging a diagnostic failure need to address both interpretive accuracy and communication of results to the ordering physicians and, when appropriate, to patients directly.

Analysis of cases with breakdowns in the testing process indicate that an unflagging assumption that reported findings are thorough and accurate, or received and understood, is not a best practice.

Results inconsistent with ongoing symptoms, other findings, or trusted instincts should be questioned to better understand where to probe further along the diagnostic pathway. Physicians who accept that infallibility is unrealistic, and pursue the range of possibilities when the puzzle pieces don’t fit, are better positioned to reach an accurate and timely diagnosis and avoid allegations of malpractice.

This article is excerpted from the 2014 Annual Benchmarking Report: Malpractice Risk in the Diagnostic Process. You can request a complete copy, for free, here.

casestudy007A87 Case Study
A misread X-ray of patient with pneumonia led to respiratory failure and death.
 data007A87

 

 

Data Analysis 
Radiology is the responsible service in nearly half of cases involving misinterpretation.
[click to enlarge]



audio007A87 Interview
Dr. Gordon Schiff talks about understanding test results. (22 sec) 

 


December 17, 2014
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