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Case Report: The Untriggered Alert

Dec 28, 2016 11:00AM ● By MED Magazine
By Lori Atkinson

A pulmonologist misses an abnormal CT report in the EHR, which contributes to a deadly delay in the diagnosis of lung cancer.

Facts of the case

A family physician referred a 78-year-old man with a history of emphysema to a pulmonologist for a prolonged productive cough and other respiratory symptoms that were not responsive to treatment. The pulmonologist ordered a chest X-ray that showed worsening interstitial primarily bibasilar infiltrates that had been present for a year. The pulmonologist felt the cough was likely related to active airway disease and recommended the patient continue his Symbicort medication, as well as return in three to four months for reevaluation. The pulmonologist also ordered a high resolution chest CT be done prior to that appointment.

Four months later, the patient returned to see the pulmonologist after having the chest CT done. The patient reported he was doing better. The pulmonologist diagnosed mild interstitial fibrosis and instructed the man to follow up as needed. The report of the chest CT done that day revealed an indeterminate 1.5 cm left lower lobe pleural-based soft tissue mass. The radiologist commented that lung carcinoma was not able to be excluded and recommended a dedicated enhanced chest CT and biopsy sampling be done. The pulmonologist did not see the abnormal chest CT report.

Eight months later, the patient returned to see the pulmonologist for complaints of increasing shortness of breath. When the pulmonologist went into the EHR to order a chest X-ray, he noticed the previous abnormal chest CT results. The pulmonologist discussed the results with the patient, noting the concern for malignancy. He ordered a thoracentesis and repeat chest CT, which showed a primary lung malignancy with combined small cell and non-small cell features. The patient chose not to have chemotherapy and hospice care was ordered.

Several months later, the man was found unresponsive at home and died later that afternoon. The cause of death was determined to be metastatic adenocarcinoma of the lung. The family filed a malpractice claim against the pulmonologist alleging failure to timely diagnose and treat lung cancer.

Disposition of the case

The case was settled with payment against the pulmonologist

Patient safety and risk management perspective

The experts who reviewed this case argued whether or not the delay in diagnosis resulted in any lost chance of survival for this man. However, they could not support the pulmonologist clearly missing an abnormal chest CT report that recommended further testing to rule out malignancy. The pulmonologist testified that he did not know how he missed the patient’s abnormal chest CT report in the EHR, but that his clinic had just implemented a new lab module that may have failed to trigger the result notification. He testified that after a root cause analysis of this adverse event, his clinic changed the workflow process for test result management.

When EHRs cause patient harm

In an analysis of EHR-related malpractice claims submitted to the claims database at CRICO Strategies/Risk Management Foundation of the Harvard Medical Institutions, researchers found that 59 percent of these cases originated in an ambulatory care setting, and that most cases were the result of an error involving medications (31 percent), a diagnosis error (28 percent) or a complication of treatment (31 percent).1

In many cases, more than one contributing factor was identified, with 63 percent of cases involving user-related issues and 58 percent involving technology-related issues. User-related issues included incorrect information, pre-populating/copy-and-paste, or training and education. System-related issues involved technology and software design, routing of electronic data, system malfunction, integration problems, or failure of alerts/decision support. The researchers suggested that strategies to reduce patient harm should target the settings most at risk (ambulatory care) and the processes that account for the most errors (medication and diagnosis).


Patient Safety and Risk Management Tips
1.    Build a common language using an eight-dimensional socio-technical model (see webinar list below) to address the challenges involved in design, development, implementation, use and evaluation of health information technology.

2.   Establish clinician-oriented “professional rights” that represent important EHR features, functions and user privileges that clinicians need in order to provide safe, high-quality care. For each right, include the corresponding “clinician responsibility.”

3.  Implement a simplified approach for conducting EHR-related surveillance activities, using “red flags” to reduce the risks associated with EHR implementation and use.

Managing Electronic Health Risk, Bundled Solution Multiple resources including the SAFER Guide assessments, toolkits, guidance and on-demand webinars, including “When EHRs Cause Patient Harm” presented by Trish Lugtu, available at Login > Risk Management > Bundled Solutions at and
1.      Graber ML, Siegal D, Riah H, Johnston D, Kenyon K. Electronic health record-related events in medical malpractice claims. J Patient Saf. Nov 6, 2015

LORI ATKINSON, RN, BSN, CPHRM, CPPS is Patient Safety Solutions Manager in Research, Development & Education at MMIC, She has been with MMIC for 26 years.