Category: Closing the Loop

Risk: Unreconciled specialist opinion/recommendation

Lack of follow up with patient due to inadequate office practice system to reconcile record from specialist visits

Diagnostic Process of Care in Ambulatory Diagnosis Cases*

A mismanaged referral is a contributing factor in 13% of CRICO (21% of Candello) ambulatory cases alleging a missed or delayed diagnosis.

Step Percent of Cases*
1. Patient notes problem and seeks care 1% 1%
2. History and physical 10% 8%
3. Patient assessment/evaluation of symptoms 35% 31%
4. Diagnostic processing 43% 35%
5. Order of diagnostic/lab test 40% 31%
6. Performance of tests 5% 3%
7. Interpretation of tests 37% 23%
8. Receipt/transmittal of test results to provider 4% 5%
9. Physician follow up with patient 21% 18%
10. Referral management 13% 21%
11. Provider-to-provider communication 12% 12%
12. Patient compliance with follow-up plan 14% 17%

* Cases with claim made date 1/11/11–8/31/16
** A case will often have multiple factors identified
† Candello is CRICO’s Comparative Benchmarking System

Closed Malpractice Case

A 74-year-old male was advised, during a hospital stay, to see a pulmonologist for a specific opacity in his right upper lobe suspicious for carcinoma seen on a CT scan.

The patient was seen shortly thereafter by his PCP, who made a referral to a pulmonologist. The PCP saw the patient for regular visits for the next four years, but was not aware of the pulmonologist’s recommendation for additional follow up regarding the lung concern. At age 78, the patient was diagnosed with stage IV lung cancer and died three months later.

Patient Safety Vulnerabilities

  1. If referrals fail to reach the office, patients or specialists, or if the information is not integrated into the care plan, patients may be at risk.

    Safer Care: To avoid “person specific” referral management, develop reliable processes to ensure 1) patients are referred to specialists in a consistent manner, 2) outstanding visits are followed up, and 3) specialist reports are brought to the attention of the patient and the care team.

  2. Communicate clearly with patients your clinical reasons for referrals and their urgency. Breakdowns in communication with the patient regarding test results, change in medical status, and when to return for unresolved concerns can lead to poor patient outcomes.

    Safer Care: When all parties are involved in referral transactions they reduce the opportunities for patients (or reports) to fall through the cracks. Inadequate systems for closed-loop communications of referrals can lead to gaps in patient care. Build a redundant system incorporating all members of the care team, including the patient.

Practice Assessment

  1. Has this type of event happen at our practice?
    Recommended practice: Analyze similar events (including near misses) for patient safety improvement opportunities.
  2. What is our system for referral management? What role does each team member (including the patient) play?
    Recommended practice: Referrals are ordered and documented in the EHR.

    Recommended practice: A procedure to identify which referrals are outstanding.
  3. How do we communicate high priority referrals to the clinical team and patient?
    Recommended practice: The reason and urgency for the referral is communicated to the patient and specialist, and an appointment is made for the patient prior to leaving the office.
  4. Do we document all patient communication in the medical record?
    Recommended practice: Provider review of all referral findings with patients is documented.

Additional Resources

Disclaimer: The CRICO Are You Safe? case studies offer suggestions for assessing and addressing patient safety and should not be construed as a standard of care.

CRICO’s mission is to provide a superior medical malpractice insurance program to our members, and to assist them in delivering the safest health care in the world. CRICO, a recognized leader in evidence-based risk management, is a group of companies owned by and serving the Harvard medical community.

How to Earn Category 2 Risk Management Credits

This Are You Safe? case study is suitable for 0.25 AMA PRA Category 2 Credit™. This activity has been designed to be suitable for .25 hours of Risk Management Study in Massachusetts. Risk Management Study is self-claimed; print and keep this page for your record keeping.

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