Case Study
Delayed Breast Cancer Diagnosis due to Automated EHR Report Error
Description
A 45-year-old woman’s abnormal screening mammogram result remained in a draft report due to an EHR automation flaw that defaulted to “normal,” leading to an incorrect notification, an 18-month delay in diagnosis of stage II breast cancer.
Key Lesson(s)
- Routinely reviewing EHR settings is important for identifying any potential risks in patient and provider communication.
- Use EHR templates to support provider workflows and optimize patient safety.
Clinical sequence
A 45-year-old woman underwent a routine screening mammogram. A radiologist read the images and began entering the results in the EHR. The EHR was designed to default to a “normal” results report and had to be manually changed in the system if the report was abnormal. The EHR also had a safeguard that would remove a report if there was an interruption or delay in documenting the report in the system. Once removed, the provider had to search for the draft report in the system in order to complete it.
In this case, the draft report documented a recommendation for further testing based on a mammogram finding. The provider was delayed and “kicked out” of the report prior to updating the automated template report stating a “normal” read. While the report was saved as a draft, an automated letter was delivered to the patient and ordering provider indicating a normal mammogram result.
Eighteen months following the screening mammogram, the patient noted a mass in her breast. A repeat mammogram confirmed the presence of a mass. Further testing revealed stage II breast cancer. The patient underwent mastectomy, radiation, and chemotherapy.
Allegation
A lawsuit was filed against the radiologist and the organization, alleging there was a delay in the diagnosis of breast cancer.
Disposition
The case settled in the medium range.
Clinical Analysis
- EHR templates and automations should aid clinician workflow and patient safety, for example in this scenario, the EHR should have pushed a notification to the provider that a note was not finalized/signed. The system should not send incomplete or unfinalized results to patients.
- With ever-evolving technologies, routine and comprehensive reviews of templates and automations should occur. These reviews should include frontline clinicians as key stakeholders.
Discussion Questions
- Do EHR templates at your organization support your role and improve safety?
- How do you regularly assess automated processes related to test results?
- Are there any risks you see with your EHR? Is there a path to address them?
Additional Resources
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