Case Reports

How could improved provider communication have improved the care this patient received?

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References

Diagnostic errors are often unreported or unrecognized, especially in the outpatient setting.3 Studies focused on reducing diagnostic error show that a second review of pathology slides reduces error, controls costs, and improves quality of health care.4

Don’t rely (exclusively) on the health record. Gaps in effective communication between providers are a leading cause of preventable adverse events.5,6 The incorporation of electronic health records has allowed for more streamlined communication between providers. However, the mere presence of patient records in a common system does not guarantee the receipt or communication of information. The next step after entering the information into the record is to communicate it.

Our patient underwent a battery of costly and unnecessary tests and procedures, many of which were unwarranted at her age. In addition to being exposed to harmful radiation, she also experienced significant stress secondary to the tests and anticipation of the results. However, a root cause analysis of the case led to an improved protocol for communication between providers at the outpatient clinic. We now emphasize the necessity of including a clinical history and corresponding physical findings with all biopsies. We also encourage more direct communication between nursing staff, primary care physicians, and specialists.

THE TAKEAWAY

As medical professionals become increasingly reliant on the many emerging studies available to them, we sometimes forget that communication is key to optimal medical care, an accurate diagnosis, and patient safety.

Continue to: In addition, a second review...

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