International Journal for Quality in Health Care 14:259-260 (2002)
© 2002 International Society for Quality in Health Care
Every Defect is a Treasure |
Breaks in care in the ambulatory care setting: the risks to patient safety
Adapted with permission by Kathleen Dwyer, MS, from Resource, November 2001. Resource is an audiotape publication of the Risk Management Foundation of the Harvard Medical Institutions, Cambridge, MA, USA.
During a 14-month period of care, a healthy 50-year-old woman reports episodes of rectal bleeding to one and later to a second internist. Absence of steps taken either to substantiate a diagnosis of hemorrhoids or to ensure that a colonoscopy is carried out leads to fatal results.
A healthy 50-year-old teacher presents to her internist with a history of occasional bleeding from hemorrhoids over several years. The patient recalls being previously diagnosed with hemorrhoids during one of her pregnancies. On rectal exam, the internist notes normal tone without masses. A stool test is negative for occult blood and no mention is made of hemorrhoids on exam. The internist recommends suppositories and discusses the need to schedule a colonoscopy with the patient. Unfortunately, neither the patient nor the physician schedules the colonoscopy.
Error occurs within systems. The system, the people, their interaction with each other, and the performance of procedures or lack thereof—all contribute to the outcome. Screening guidelines aside, a good office system approach that emphasizes personal interactions with patients, includes recommendations that involve the patient and his or her preference, requires documentation that instructs and assigns responsibility for follow-up, promotes patient safety. In this case, because the physician recommends an over-the-counter remedy, the patient is led to believe that her medical problem is to be attributed solely to the presence of hemorrhoids. The real risks of not doing the screening test are not made clear to her. Since patients are naturally hesitant about some tests, it is important for the clinician to explain why a test is chosen, and to ‘walk them through’ the test so that they understand every phase of what they are about to face. Research shows that scheduling the test while the patient is in the office improves compliance. On the part of the care system, multiple checks and balances must be in place for following up on test results until these results are received: for example, computer software, a ‘tickler’ system, a designated staff person, and a back-up person for occasions when the designated staff member is absent.
The following year, a new internist assumes the patient’s care. On her annual visit, the patient again raises the issue of occasional bleeding from hemorrhoids over a period of several years. The patient’s stools are tested for occult blood and are found to be negative. The internist apparently assumes that the rectal bleeding is from hemorrhoids. Of note, the colonoscopy originally recommended is still not scheduled or carried out.
How is it that good physicians become distracted? This happens frequently. In the current case, a woman with persistent complaints of hemorrhoids needs to receive confirmation of this diagnosis or to have more serious pathology ruled out. Although the physical exams were thorough, the failure to work up the rectal bleeding was a significant oversight on the part of the two internists. A patient’s preliminary assessment of her condition should not dissuade the physician from conducting a complete evaluation. On a different front, having access to the right information provides better communication, better documentation, and ultimately better patient care. To that end, implementing a reliable tickler system or electronic reminders can help prevent ‘the passage of error’ that occurred in this case.
Over the next year, the internist sees the patient episodically. Several specialists also see her for neurological symptoms including generalized weakness and numbness. On one occasion, the patient is hospitalized to rule out multiple sclerosis. A few months later at her annual physical exam, the patient tells her internist that she still experiences occasional bleeding from her hemorrhoids. The internist assesses that there is ‘no problem at this time’.
Ambulatory practice is often constrained by reduced time per visit. This constraint, in combination with increased complexity of patient information and documentation requirements, can often mean that secondary problems take a back seat to more pressing health concerns—in this case to multiple sclerosis. The presence of an updated problem list or a computerized system that carries a summary of the patient’s problems on one or two screens might avert problems down the road due to forgetfulness and the loss of information from inpatient to outpatient sites.
Two months later, the patient returns to her internist and reports a number of symptoms—increased rectal pain, incomplete evacuation, and bright red blood on evacuation—which have worsened over the past six weeks. On rectal exam, tenderness is noted along the inner aspect of the anal sphincter. A subsequent colonoscopy performed by a surgeon reveals a large rectal cancer. Despite extensive surgery, chemotherapy, and radiation treatments, the patient dies one year later.
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