When Test Results Go Unspoken

Description

An abnormal finding from a computed tomography angiogram (CTA) scan was not communicated to the patient, leading to a delayed diagnosis of lung cancer and shortened life expectancy.

Key Lessons

• It is important to have polices and protocols in place to notify providers and patients of abnormal findings on test results.
• Clear communication between providers and with patients is essential for follow-up.
• Ambulatory safety nets (ASNs) can assist in closing the loop on abnormal test results to ensure that necessary follow-up care is received.

Clinical Sequence

A nurse practitioner (NP) ordered a low-dose lung cancer CTA for a 60-year-old patient with a medical history of long-term heavy smoking, hypertension, and anxiety. A radiologist read the CTA results, which showed a 3 cm mass in the left lung suspicious for adenocarcinoma, and they recommended a bronchoscopy for further diagnosis.

The patient did not receive the CTA results and did not follow up with the NP.  The NP had routine appointments with the patient; however, there was no discussion or inquiries about the CTA results.

Two years later, another provider at the same facility examined the patient and ordered another CTA. At this time, the patient asked the provider about his previous CTA results. The provider was unaware of the prior CTA. The new CTA results showed that the mass had grown and metastasized to both lungs and his liver. 

Further review of both CTAs showed the disease progression from the first to second scan. The patient’s cancer advanced from Stage II to Stage IV. Despite ongoing care and treatment, the patient experienced a decreased life expectancy due to the delay in diagnosis.

Allegation

The claimant alleged there was a failure to notify the patient of an abnormal finding on a screening CT that resulted in a delayed diagnosis of lung cancer and metastasis to liver and spine.

Disposition

This case settled in the high range ($500,000–$999,999).

Clinical Analysis

During the review of this case, the key factors contributing to the claim included:

Need for policy/protocol: There was an absence of established protocols to ensure that ordered test results were properly received and communicated to patients.

Communication among providers regarding the patient’s condition: The radiologist should have reported abnormal findings to the NP.

Failure in patient communication and follow-up: There was no communication with the patient regarding the abnormal findings. The patient assumed screening was routine, so no news meant negative results.

Lack of systematic patient follow-up for abnormal test results. Closing the loop on abnormal test results and referrals is essential to ensure the patient receives appropriate follow-up. For example, implementing a backup system such as Ambulatory Safety Nets for following up on abnormal test results can help to ensure that closed-loop communication and documentation are completed. Ambulatory safety nets are high-reliability, person-centered programs that can assist with:

• Registries for patients with abnormal results/outstanding referrals
• Communication workflows
• Patient navigators

Discussion Questions

1. What is your organization’s policy/procedure for follow-up on test results?
2. How can communication between providers be strengthened when delivering critical test results?
3. What strategies can be used to enhance communication with the patient following the ordering of tests?