In health care, communication can be a matter of life or death. Take the case of an American woman diagnosed with a blood clot in her leg. She died suddenly of a pulmonary embolism the following day, while both a faxed and emailed report of her life-threatening condition sat unread in her doctor’s surgery.
A complex medical malpractice case, initiated in 2008 and still in the US courts, revealed that her frustrated radiologist hung up when he got the doctor’s answering service without leaving a message. An administrator at the medical practice received the emailed and faxed results and notified the doctor they were in – but not that they were urgent and that no one had read them.
Consequently, no potentially life-saving anti-coagulant treatment was initiated.
Much of the interest around the case lies in determining who is at fault and, especially, in any monetary damages which will eventually be awarded to the woman’s family. But what is so striking is just how ordinary the events were that led to such a catastrophic outcome, and how easily such vital chains of communication can break down.
So much so, that the failure to follow up test results is an increasingly serious patient safety issue around the world.
The results of our systematic review of the best evidence available internationally found up to 62% of laboratory tests and up to 36% of radiology tests for patients attending GP clinics and hospital outpatient departments are not reviewed by doctors. This includes tests that are returned positive for cancer cells.
The findings are published in the current edition of the Journal of General Internal Medicine.
The potential for harm if a critical diagnosis is overlooked is obvious. For every single patient admitted to hospital in Australia, for example, an average of 100 tests are performed.
Yet, there is not a single law or regulation requiring health care professionals to follow up results in Australia. Patients often rely on the assumption that “no news is good news” when, in fact, no news may mean the results are languishing in the email inbox or the in tray.
What might outcomes be, then, if the mysterious world of pathology and radiology was suddenly thrown open?
What if labs and radiology departments phoned or sent through test results in clear, simple to understand terms directly to the person who has the most at stake: the patient, or his or her immediate carer?
In many health systems, including Australia’s, this would be a big cultural change.
Our related recent research into the views of Australian emergency doctors at one major hospital found 21.2% believed they had missed a test result themselves over the past year, leading to a delay in treatment. And 47.4% believed a colleague had missed a test results. Half the emergency doctors didn’t know who was ultimately responsible if a result was overlooked, but only half would be comfortable if patients received their results directly.
The medical profession’s reluctance is based mainly on reasonable fears of triggering anxiety, panic or confusion among a public that is mostly unqualified to read lab and radiology reports. Certainly, the way results are presented would need to change and support services would have to be put in place.
It might, however, be as simple as a “your results require follow up” email, followed by a “what to do now” click-through link or directions to a phone information and counselling service.
Technology offers potential new solutions, such as the electronic tracking of results to ensure that they have not only been seen but that they have been “actioned”, with follow-up documented.
Patients, too, could simply be given direct access to their health records online, something which is increasingly feasible as people opt in to electronic health records systems around the world, and in Australia.
No single solution will protect all patients; health care systems and the communications chains they require are extremely complex. This means critical information can fall through the cracks despite the best efforts of individuals.
But, there is a known danger in the status quo. Although our systematic review relied on data from the United States, where most research is being undertaken, it is fair to assume the risk of harm in Australia is much the same, given strong anecdotal evidence and the similarities of the health care systems.
In the US, all mammogram results have been reported directly to patients since national legislation was introduced in 1998. And increasingly, US radiology practices are voluntarily communicating results directly to patients with positive feedback. This suggests many people are, in fact, willing and able to take more responsibility for their own health.
In Australia, we need to consider every option. Given the huge and rising costs of medical testing and the consequences of delayed treatment in terms of both patient suffering and health care dollars, there is good reason to act urgently.
Australia has many excellent health-care providers with very good follow-up processes. Many test results are completely normal and so the failure to follow-up has no impact at all.
But just one record left unread is a potential personal tragedy if it means critical care is not delivered in time.