A 29-year-old male was seen at Best Health Clinic, a family medicine clinic, for the first time by Dr. Smith in April 2009. The patient’s main problem was bronchitis, which was evaluated and treated appropriately. The patient also mentioned a new mole on his right arm and he was set up for a biopsy in May 2009. The biopsy was performed and sent to Bestpath. The biopsy report was never seen in the clinic. It was either not forwarded or received and not attached to the chart.
The patient was seen multiple times over the next few years and the pathology result was never mentioned. Finally, in February 2011, the patient presented with another mole in the same area and it was also biopsied and sent to Bestpath. This was a melanoma and triggered a search for the first biopsy. Eventually, it was discovered that the first 2009 biopsy had also shown a melanoma.
Bestpath’s explanation was that it received the biopsy in May 2009. At that time, the pathologist who examined the biopsy felt that there was unusual compound melanocyte proliferation. The pathology was forwarded to a center of excellence for a second opinion, and in June 2009, it was diagnosed as malignant melanoma. This report was sent to Bestpath in late June 2009.
Dr. Smith does not believe he is responsible as he never received the report. Best Health Clinic states that it never received the report. Upon further review, it did not appear that the clinic had a good tracking system for its lab, X-ray and pathology reports.
Bestpath stated that its standard procedure is to send the report to the physician, but it could not prove that this this particular report had been sent to the Best Health Clinic.
The patient was eventually diagnosed with stage IV melanoma. Dr. Smith and Bestpath both settled in 2012 with the patient for a large sum of money.
In Mark Graber’s landmark 2005 study[i] titled “Diagnostic Error in Internal Medicine,” there was an examination of 100 cases of diagnostic errors in the hospital setting. He identified 548 different system-related or cognitive factors (5.9 per case). System-related factors contributed to the diagnostic error in 65 percent of the cases and cognitive factors in 74 percent. The most common system-related factors involved problems with policies and procedures, inefficient processes, teamwork, and communication. His conclusion was “Diagnostic error is commonly multifactorial in origin, typically involving both system-related and cognitive factors.”
Read more about the studies surrounding diagnostic errors as well as our patient safety recommendations for avoing communication and tracking errors by clicking below.