Postreferral colonoscopy delays in diagnosis of colorectal cancer: a mixed-methods analysis. Qual Manag Health Care. 2013;21:252-261. [PMID: 23011072 DOI: 10.1097/qmh.0b013e31826d1f28]

Interventions to improve timely cancer diagnosis: an integrative review

Cancer will affect more than one in three U.S. residents in their lifetime, and although the diagnosis will be made efficiently in most of these cases, roughly one in five patients will experience a delayed or missed diagnosis. In this integrative review, we focus on missed opportunities in the diagnosis of breast, lung, and colorectal cancer in the ambulatory care environment. From a review of 493 publications, we summarize the current evidence regarding the contributing factors to missed or delayed cancer diagnosis in ambulatory care, as well as evidence to support possible strategies for intervention. Cancer diagnoses are made after follow-up of a positive screening test or an incidental finding, or most commonly, by following up and clarifying non-specific initial presentations to primary care. Breakdowns and delays are unacceptably common in each of these pathways, representing failures to follow-up on abnormal test results, incidental findings, non-specific symptoms, or consults. Interventions aimed at 'closing the loop' represent an opportunity to improve the timeliness of cancer diagnosis and reduce the harm from diagnostic errors. Improving patient engagement, using 'safety netting,' and taking advantage of the functionality offered through health information technology are all viable options to address these problems.

CHOICE: A Comprehensive and Coordinated Colorectal Cancer Screening Program in a Large Urban Health System

OBJECTIVE

To develop a coordinated colorectal cancer (CRC) screening program within a large urban health system, with the ultimate goal of increasing system-wide screening rates of eligible patients and reducing no-show rates while increasing colonoscopy completion rates.

STUDY SETTING

A large urban academic health system comprising 8 hospitals and over 400 ambulatory practices.

STUDY DESIGN

The CHOICE Program combined patient navigation, electronic medical record (EMR) optimization, and system-wide practice changes to improve CRC screening completion by colonoscopy. The program incorporates provider and patient education, standardization of documentation and protocols, increased outreach by navigators, and streamlining of patient scheduling. The primary outcome is colonoscopy completion.

DATA COLLECTION

All health system patients between the ages of 45 and 75 and at average risk of CRC are the target population for the intervention. A review of screen-eligible patients' completion of colonoscopy was performed to assess program success.

PRINCIPAL FINDINGS

During a 2-year period (March 2022 to February 2024), 18,119 people were referred into the program, and 79% of scheduled patients completed the colonoscopy. The CHOICE program operationalized and standardized the CRC screening efforts of a large health system and offers a template that can be implemented or adapted by other hospital systems and provider networks.

Negative spillover due to constraints on care delivery: a potential source of bias in pragmatic clinical trials

BACKGROUND

Pragmatic clinical trials evaluate the effectiveness of health interventions in real-world settings. Negative spillover can arise in a pragmatic trial if the study intervention affects how scarce resources are allocated across patients in the intervention and comparison groups.

MAIN BODY

Negative spillover can lead to overestimation of treatment effect and harm to patients assigned to usual care in trials of diverse health interventions. While this type of spillover has been addressed in trials of social welfare and public health interventions, there is little recognition of this source of bias in the medical literature. In this commentary, I examine what causes negative spillover and how it may have led clinical trial investigators to overestimate the effect of patient navigation, AI-based physiological alarms, and elective induction of labor. Trials discussed here are a convenience sample and not the result of a systematic review. I also suggest ways to detect negative spillover and design trials that avoid this potential source of bias.

CONCLUSION

As new clinical practices and technologies that affect care delivery are considered for widespread adoption, well-designed trials are needed to provide valid evidence on their risks and benefits. Understanding all sources of bias that could affect these trials, including negative spillover, is a critical part of this effort. Future guidance on clinical trial design should consider addressing this form of spillover, just as current guidance often discusses bias due to lack of blinding, differential attrition, or contamination.

Sampling error in the diagnosis of colorectal cancer is associated with delay to surgery: a retrospective cohort study

BACKGROUND

Accurate histopathologic diagnosis of colorectal cancer is important for treatment decision-making and timely care. The aim of this study was to measure rates and predictors of sampling errors for biopsy specimens attained at flexible lower gastrointestinal endoscopy, and to determine whether these events lead to a delay in surgical care.

METHODS

This is a retrospective observational study of patients who underwent elective resection for colorectal adenocarcinoma between January 2007 and June 2020. Primary outcomes were proportion of incorrectly diagnosed colorectal adenocarcinomas at index endoscopy by histopathology, and time between endoscopy and surgery. Secondary outcomes were predictors of sampling error, and diagnostic yield of repeat endoscopy.

RESULTS

Sampling errors occurred in 217/962 (22.6%) flexible endoscopies for colorectal adenocarcinomas. Negative biopsies were associated with a longer median time to surgery (87.6 days, IQR 48.8-180.0) compared to true positive biopsies (64.0 days, IQR 38.0-119.0), p < 0.001. Controlling for lesion location, neoadjuvant therapy, endoscopist specialty, year, and repeat endoscopies, time to surgery remained 1.40-fold longer (p < 0.001) following sampling error. Repeat endoscopy occurred following 62/217 (28.6%) cases of sampling errors, yielding a correct diagnosis of cancer in 38/62 (61.3%) cases. On multivariable analysis, sampling errors were less likely to occur for lesions endoscopists described as suspicious for malignancy (OR 0.12, 95% CI 0.07-0.21) or simple polyps (OR 0.24, 95% CI 0.08-0.70) compared to endoscopically unresectable polyps.

CONCLUSIONS

Colorectal cancers are frequently improperly sampled, which may lead to treatment delays for these patients. When cancer is suspected, surgeons should take care to ensure timely management.

Health Insurance Status as a Predictor of Mode of Colon Cancer Detection but Not Stage at Diagnosis: Implications for Early Detection

OBJECTIVE

For colon cancer patients, one goal of health insurance is to improve access to screening that leads to early detection, early-stage diagnosis, and polyp removal, all of which results in easier treatment and better outcomes. We examined associations among health insurance status, mode of detection (screen detection vs symptomatic presentation), and stage at diagnosis (early vs late) in a diverse sample of patients recently diagnosed with colon cancer from the Chicago metropolitan area.

METHODS

Data came from the Colon Cancer Patterns of Care in Chicago study of racial and socioeconomic disparities in colon cancer screening, diagnosis, and care. We collected data from the medical records of non-Hispanic Black and non-Hispanic White patients aged ≥50 and diagnosed with colon cancer from October 2010 through January 2014 (N = 348). We used logistic regression with marginal standardization to model associations between health insurance status and study outcomes.

RESULTS

After adjusting for age, race, sex, and socioeconomic status, being continuously insured 5 years before diagnosis and through diagnosis was associated with a 20 (95% CI, 8-33) percentage-point increase in prevalence of screen detection. Screen detection in turn was associated with a 15 (95% CI, 3-27) percentage-point increase in early-stage diagnosis; however, nearly half (47%; n = 54) of the 114 screen-detected patients were still diagnosed at late stage (stage 3 or 4). Health insurance status was not associated with earlier stage at diagnosis.

CONCLUSIONS

For health insurance to effectively shift stage at diagnosis, stronger associations are needed between health insurance and screening-related detection; between screening-related detection and early stage at diagnosis; or both. Findings also highlight the need to better understand factors contributing to late-stage colon cancer diagnosis despite screen detection.

A Root Cause Analysis of Barriers to Timely Colonoscopy in California Safety-Net Health Systems

OBJECTIVES

Safety-net health care systems, serving vulnerable populations, see longer delays to timely colonoscopy after a positive fecal occult blood test (FOBT), which may contribute to existing disparities. We sought to identify root causes of colonoscopy delay after positive FOBT result in the primary care safety net.

METHODS

We conducted a multisite root cause analysis of cases of delayed colonoscopy, identifying cases where there was a delay of greater than 6 months in completing or scheduling a follow-up colonoscopy after a positive FOBT. We identified cases across 5 California health systems serving low-income, vulnerable populations. We developed a semistructured interview guide based on precedent work. We conducted telephone individual interviews with primary care providers (PCPs) and patients. We then performed qualitative content analysis of the interviews, using an integrated inductive-deductive analytic approach, to identify themes related to recurrent root causes of colonoscopy delay.

RESULTS

We identified 12 unique cases, comprising 5 patient and 11 PCP interviews. Eight patients completed colonoscopy; median time to colonoscopy was 11.0 months (interquartile range, 6.3 months). Three patients had advanced adenomatous findings. Primary care providers highlighted system-level root causes, including inability to track referrals between primary care and gastroenterology, lack of protocols to follow up with patients, lack of electronic medical record interoperability, and lack of time or staffing resources, compelling tremendous additional effort by staff. In contrast, patients' highlighted individual-level root causes included comorbidities, social needs, and misunderstanding the importance of the FOBT. There was a little overlap between PCP and patient-elicited root causes.

CONCLUSIONS

Current protocols do not accommodate communication between primary care and gastroenterology. Interventions to address specific barriers identified include improved interoperability between PCP and gastroenterology scheduling systems, protocols to follow-up on incomplete colonoscopies, accommodation for support and transport needs, and patient-friendly education. Interviewing both patients and PCPs leads to richer analysis of the root causes leading to delayed diagnosis of colorectal cancer.

Automated Time-Released Reminders Improve Patient Access to Colonoscopy

Unscheduled colonoscopy orders lead to missed opportunities for early diagnosis and screening. The aim of this study was to evaluate the effect of an automated time-released reminder program on conversion of colonoscopy orders to scheduled cases. In this prospective study, we compared patients ordered for a colonoscopy who were enrolled in an automated reminder program (intervention) with a historical cohort of patients ordered for a colonoscopy who did not receive scheduling reminders (control). The intervention group received automated text message and email reminders using a software platform at 1, 7, and 14 days after a colonoscopy order was placed. The percentage of colonoscopies scheduled within 14 days of order placement improved from 66.0% in the control group to 73.4% in the intervention group (p = .001). The percentage of colonoscopies scheduled within 30 days improved from 73.6% to 90.0% (p < .0001). For colonoscopies ordered by a nongastroenterologist, the percentage of cases scheduled within 30 days of order placement improved from 65.8% in the control group to 90.0% in the intervention group (p < .0001). There was a 10% decrease in phone calls with endoscopy staff for the intervention group relative to the control group. Automated reminders for colonoscopy scheduling improve efficiency in colonoscopy scheduling.

Measures to Improve Diagnostic Safety in Clinical Practice

Timely and accurate diagnosis is foundational to good clinical practice and an essential first step to achieving optimal patient outcomes. However, a recent Institute of Medicine report concluded that most of us will experience at least one diagnostic error in our lifetime. The report argues for efforts to improve the reliability of the diagnostic process through better measurement of diagnostic performance. The diagnostic process is a dynamic team-based activity that involves uncertainty, plays out over time, and requires effective communication and collaboration among multiple clinicians, diagnostic services, and the patient. Thus, it poses special challenges for measurement. In this paper, we discuss how the need to develop measures to improve diagnostic performance could move forward at a time when the scientific foundation needed to inform measurement is still evolving. We highlight challenges and opportunities for developing potential measures of "diagnostic safety" related to clinical diagnostic errors and associated preventable diagnostic harm. In doing so, we propose a starter set of measurement concepts for initial consideration that seem reasonably related to diagnostic safety and call for these to be studied and further refined. This would enable safe diagnosis to become an organizational priority and facilitate quality improvement. Health-care systems should consider measurement and evaluation of diagnostic performance as essential to timely and accurate diagnosis and to the reduction of preventable diagnostic harm.

Colonoscopy resource availability and its association with the colorectal cancer diagnostic interval: A population-based cross-sectional study

BACKGROUND

Colonoscopy is a key resource used to diagnose colorectal cancer (CRC). This study evaluated the relationship between colonoscopy availability and the length of the CRC diagnostic interval.

METHODS

This is a cross-sectional study of CRC patients diagnosed in Ontario, Canada, in 2008-2012. We used administrative health data to characterise colonoscopist density, private colonoscopy clinic access, distance to the closest colonoscopist and the diagnostic interval, defined as the time from patients' first cancer-related healthcare encounter to their cancer diagnosis date. We used multivariable quantile regression to evaluate the association between colonoscopy availability and the diagnostic interval, modelling the median and 90th percentile.

RESULTS

The median diagnostic interval was 84 days (90th percentile 323 days). The diagnostic interval was longer in patients residing in areas with lower colonoscopists density or private clinic access (adjusted median difference = 9 and 19 days, respectively), with evidence of effect modification by symptom status. Increased distance to a colonoscopist was associated with a longer diagnostic interval in asymptomatic patients, but a shorter diagnostic interval in symptomatic patients (adjusted median difference = 29 and -25 days, respectively).

CONCLUSIONS

This study demonstrated that reduced colonoscopy resource availability is associated with longer diagnostic intervals for CRC patients.

Diagnostic Evaluation of Patients Presenting to Primary Care with Rectal Bleeding

BACKGROUND

Rectal bleeding is a common, frequently benign problem that can also be an early sign of colorectal cancer. Diagnostic evaluation for rectal bleeding is complex, and clinical practice may deviate from available guidelines.

OBJECTIVE

To assess the degree to which primary care physicians document risk factors for colorectal cancer among patients with rectal bleeding and order colonoscopies when indicated, and the likelihood of physicians ordering and patients receiving recommended colonoscopies based on demographic characteristics, visit patterns, and clinical presentations.

DESIGN

Cross-sectional study using explicit chart abstraction methods.

PARTICIPANTS

Three hundred adults, 40-80 years of age, presenting with rectal bleeding to 15 academically affiliated primary care practices between 2012 and 2016.

MAIN MEASURES

1) The frequency at which colorectal cancer risk factors were documented in patients' charts, 2) the frequency at which physicians ordered colonoscopies and patients received them, and 3) the odds of ordering and patients receiving recommended colonoscopies based on patient demographic characteristics, visit patterns, and clinical presentations.

KEY RESULTS

Risk factors for colorectal cancer were documented between 9% and 66% of the time. Most patients (89%) with rectal bleeding needed a colonoscopy according to a clinical guideline. Physicians placed colonoscopy orders for 74% of these patients, and 56% completed the colonoscopy within a year (36% within 60 days). The odds of physicians ordering recommended colonoscopies were significantly higher in patients aged 50-64 years of age than in those aged 40-50 years (OR = 2.23, 95% CI: 1.04, 4.80), and for patients whose most recent colonoscopy was 5 or more years ago (OR = 4.04, 95% CI: 1.50, 10.83). The odds of physicians ordering and patients receiving recommended colonoscopies were significantly lower for each primary care visit unrelated to rectal bleeding (OR = 0.85, 95% CI: 0.75, 0.96).

CONCLUSIONS

Diagnostic evaluation of patients presenting to primary care with rectal bleeding may be suboptimal because of inadequate risk factor assessment and prioritization of patients' other concurrent medical problems.

The global burden of diagnostic errors in primary care

Diagnosis is one of the most important tasks performed by primary care physicians. The World Health Organization (WHO) recently prioritized patient safety areas in primary care, and included diagnostic errors as a high-priority problem. In addition, a recent report from the Institute of Medicine in the USA, 'Improving Diagnosis in Health Care', concluded that most people will likely experience a diagnostic error in their lifetime. In this narrative review, we discuss the global significance, burden and contributory factors related to diagnostic errors in primary care. We synthesize available literature to discuss the types of presenting symptoms and conditions most commonly affected. We then summarize interventions based on available data and suggest next steps to reduce the global burden of diagnostic errors. Research suggests that we are unlikely to find a 'magic bullet' and confirms the need for a multifaceted approach to understand and address the many systems and cognitive issues involved in diagnostic error. Because errors involve many common conditions and are prevalent across all countries, the WHO's leadership at a global level will be instrumental to address the problem. Based on our review, we recommend that the WHO consider bringing together primary care leaders, practicing frontline clinicians, safety experts, policymakers, the health IT community, medical education and accreditation organizations, researchers from multiple disciplines, patient advocates, and funding bodies among others, to address the many common challenges and opportunities to reduce diagnostic error. This could lead to prioritization of practice changes needed to improve primary care as well as setting research priorities for intervention development to reduce diagnostic error.

Information seeking and anxiety among colonoscopy-naïve adults: Direct-to-colonoscopy vs traditional consult-first pathways

AIM

To investigate the effects of direct to colonoscopy pathways on information seeking behaviors and anxiety among colonoscopy-naïve patients.

METHODS

Colonoscopy-naïve patients at two tertiary care hospitals completed a survey immediately prior to their scheduled outpatient procedure and before receiving sedation. Survey items included clinical pathway (direct or consult), procedure indication (cancer screening or symptom investigation), telephone and written contact from the physician endoscopist office, information sources, and pre-procedure anxiety. Participants reported pre-procedure anxiety using a 10 point scale anchored by “very relaxed” (1) and “very nervous” (10). At least three months following the procedure, patient medical records were reviewed to determine sedative dose, procedure indications and any adverse events. The primary comparison was between the direct and consult pathways. Given the very different implications, a secondary analysis considering the patient-reported indication for the procedure (symptoms or screening). Effects of pathway (direct vs consult) were compared both within and between the screening and symptom subgroups.

RESULTS

Of 409 patients who completed the survey, 34% followed a direct pathway. Indications for colonoscopy were similar in each group. The majority of the participants were women (58%), married (61%), and internet users (81%). The most important information source was family physicians (Direct) and specialist physicians (Consult). Use of other information sources, including the internet (20% vs 18%) and Direct family and friends (64% vs 53%), was similar in the Direct and Consult groups, respectively. Only 31% of the 81% who were internet users accessed internet health information. Most sought fundamental information such as what a colonoscopy is or why it is done. Pre-procedure anxiety did not differ between care pathways. Those undergoing colonoscopy for symptoms reported greater anxiety [mean 5.3, 95%CI: 5.0-5.7 (10 point Likert scale)] than those for screening colonoscopy (4.3, 95%CI: 3.9-4.7).

CONCLUSION

Procedure indication (cancer screening or symptom investigation) was more closely associated with information seeking behaviors and pre-procedure anxiety than care pathway.

Delayed Workup of Rectal Bleeding in Adult Primary Care: Examining Process-of-Care Failures

BACKGROUND

Although delayed colorectal cancer diagnoses figure prominently in medical malpractice claims, little is known about the quality of primary care clinicians' workup of rectal bleeding.

METHODS

In this study, 438 patients were identified using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes for rectal bleeding, hemorrhoids, and blood in the stool at 10 Boston adult primary care practices. Following nurse chart abstraction, physician reviewers assessed the overall quality of care and key care processes. Subjects' characteristics and physician reviewers' processes-of-care assessments were tabulated, and logistic regression models were used to examine the association of process failures with overall quality and guideline concordance.

RESULTS

Although reviewers judged the overall quality of care to be good or excellent in 337 (77%) of 438 cases, 312 (71%) patients experienced at least one process-of-care failure in the workup of rectal bleeding. Clinicians failed to obtain an adequate family history in 38% of cases, complete a pertinent physical exam in 23%, and order laboratory tests in 16%. Failure to order or perform tests, or to make follow-up plans were associated with increased odds of poor or fair care. Guideline concordance bore little relationship with quality judgments. Reviewers judged that 128 delays could have been reduced or prevented.

CONCLUSION

Process-of-care failures among adult primary care patients with rectal bleeding were frequent and associated with fair or poor quality. Educating practitioners and creating systems to ensure adequate history taking, physical examination, and processes for ordering, performing, and interpreting diagnostic tests may improve performance.

Patient-Reported Attributions for Missed Colonoscopy Appointments in Two Large Healthcare Systems

BACKGROUND

Missed colonoscopy appointments (no-shows) can lead to wasted resources and delays in colorectal cancer diagnosis, an area of special concern in public health systems that often provide care for vulnerable patients. Our objective was to identify reasons for missed colonoscopy appointments in patients seeking care at two large public health systems in Houston, TX.

METHODS

We conducted a telephone survey of patients who missed their colonoscopy appointments at two tertiary care health systems. Using a structured survey instrument, we collected information on patient-specific and health services barriers. Patient-specific barriers included perceived procedural-related factors (e.g., difficulty in preparation), cognitive-emotional factors (e.g., fear or concern about modesty), and changes in health status (e.g., improvement or worsening of health). Health services barriers included logistical factors (e.g., travel-related difficulties) and appointment scheduling problems (inconvenient date or time). We examined differences in attributions for missed appointments between the two study sites.

RESULTS

Of 160 unique patients (102 Site A and 58 Site B) who missed their appointment during the study period, 153 (95.6 %) attributed their no-show to at least one of the listed barriers. Most respondents (125; 78.1 %) cited travel-related issues or scheduling problems as reasons for their missed appointment. Not having a ride or a travel companion was the most commonly reported travel-related issue. We also found significant differences for barriers between the two sites.

CONCLUSIONS

Most missed colonoscopy appointments resulted from potentially preventable travel- and scheduling-related issues. Because barriers to keeping colonoscopy appointments are different across health systems, each health system might need to develop unique interventions to reduce missed colonoscopy appointments.

Understanding missed opportunities for more timely diagnosis of cancer in symptomatic patients after presentation

The diagnosis of cancer is a complex, multi-step process. In this paper, we highlight factors involved in missed opportunities to diagnose cancer more promptly in symptomatic patients and discuss responsible mechanisms and potential strategies to shorten intervals from presentation to diagnosis. Missed opportunities are instances in which post-hoc judgement indicates that alternative decisions or actions could have led to more timely diagnosis. They can occur in any of the three phases of the diagnostic process (initial diagnostic assessment; diagnostic test performance and interpretation; and diagnostic follow-up and coordination) and can involve patient, doctor/care team, and health-care system factors, often in combination. In this perspective article, we consider epidemiological 'signals' suggestive of missed opportunities and draw on evidence from retrospective case reviews of cancer patient cohorts to summarise factors that contribute to missed opportunities. Multi-disciplinary research targeting such factors is important to shorten diagnostic intervals post presentation. Insights from the fields of organisational and cognitive psychology, human factors science and informatics can be extremely valuable in this emerging research agenda. We provide a conceptual foundation for the development of future interventions to minimise the occurrence of missed opportunities in cancer diagnosis, enriching current approaches that chiefly focus on clinical decision support or on widening access to investigations.

A vision for using online portals for surveillance of patient-centered communication in cancer care

The Veterans Health Administration (VHA) is charged with providing high-quality health care, not only in terms of technical competence but also with regard to patient-centered care experiences. Patient-centered coordination of care and communication are especially important in cancer care, as deficiencies in these areas have been implicated in many cases of delayed cancer diagnosis and treatment. Additionally, because cancer care facilities are concentrated within the VHA system, geographical and system-level barriers may present prominent obstacles to quality care. Systematic assessment of patient-centered communication (PCC) may help identify both individual veterans who are at risk of suboptimal care and opportunities for quality improvement initiatives at the service, facility, or system-wide level. In this manuscript, we describe our vision to implement an assessment of PCC through patient self-report to improve the quality of cancer care and other health services in the VHA. We outline a possible strategy to assess PCC that leverages the VHA's existing initiative to promote use of an online personal health record for veterans (MyHealtheVet). Questionnaires administered periodically or following specific episodes of care can be targeted to assess PCC in cancer care. Assessment of PCC can also be tied to clinical and administrative data for more robust analysis of patient outcomes. Ultimately, the goal of any assessment of PCC is to gather valid, actionable data that can assist VHA clinicians and staff with providing the best possible care for veterans with cancer.

Resilient actions in the diagnostic process and system performance

OBJECTIVES

Systemic issues can adversely affect the diagnostic process. Many system-related barriers can be masked by 'resilient' actions of frontline providers (ie, actions supporting the safe delivery of care in the presence of pressures that the system cannot readily adapt to). We explored system barriers and resilient actions of primary care providers (PCPs) in the diagnostic evaluation of cancer.

METHODS

We conducted a secondary data analysis of interviews of PCPs involved in diagnostic evaluation of 29 lung and colorectal cancer cases. Cases covered a range of diagnostic timeliness and were analysed to identify barriers for rapid diagnostic evaluation, and PCPs' actions involving elements of resilience addressing those barriers. We rated these actions according to whether they were usual or extraordinary for typical PCP work.

RESULTS

Resilient actions and associated barriers were found in 59% of the cases, in all ranges of timeliness, with 40% involving actions rated as beyond typical. Most of the barriers were related to access to specialty services and coordination with patients. Many of the resilient actions involved using additional communication channels to solicit cooperation from other participants in the diagnostic process.

DISCUSSION

Diagnostic evaluation of cancer involves several resilient actions by PCPs targeted at system deficiencies. PCPs' actions can sometimes mitigate system barriers to diagnosis, and thereby impact the sensitivity of 'downstream' measures (eg, delays) in detecting barriers. While resilient actions might enable providers to mitigate system deficiencies in the short run, they can be resource intensive and potentially unsustainable. They complement, rather than substitute for, structural remedies to improve system performance. Measures to detect and fix system performance issues targeted by these resilient actions could facilitate diagnostic safety.

Exploring situational awareness in diagnostic errors in primary care

OBJECTIVE

Diagnostic errors in primary care are harmful but poorly studied. To facilitate the understanding of diagnostic errors in real-world primary care settings that use electronic health records (EHRs), this study explored the use of the situational awareness (SA) framework from aviation human factors research.

METHODS

A mixed-methods study was conducted involving reviews of EHR data followed by semi-structured interviews of selected providers from two institutions in the USA. The study population included 380 consecutive patients with colorectal and lung cancers diagnosed between February 2008 and January 2009. Using a pre-tested data collection instrument, trained physicians identified diagnostic errors, defined as lack of timely action on one or more established indications for diagnostic work-up for lung and colorectal cancers. Twenty-six providers involved in cases with and without errors were interviewed. Interviews probed for providers' lack of SA and how this may have influenced the diagnostic process.

RESULTS

Of 254 cases meeting inclusion criteria, errors were found in 30 of 92 (32.6%) lung cancer cases and 56 of 167 (33.5%) colorectal cancer cases. Analysis of interviews related to error cases revealed evidence of lack of one of four levels of SA applicable to primary care practice: information perception, information comprehension, forecasting future events, and choosing appropriate action based on the first three levels. In cases without error, application of the SA framework provided insight into processes involved in attention management.

CONCLUSIONS

A framework of SA can help analyse and understand diagnostic errors in primary care settings that use EHRs.