Help Identify Common Factors In Delayed Diagnosis

Delays in diagnosis and treatment are widely considered to be threats to outpatient safety. However, few studies have identified and described what factors contribute to delays that might result in patient harm in the outpatient setting. We analyzed 111 root cause analysis reports that investigated such delays and were submitted to the Veterans Affairs National Center for Patient Safety in the period 2005–12. The most common contributing factors noted in the reports included coordination problems resulting from inadequate follow-up planning, delayed scheduling for unspecified reasons, inadequate tracking of test results, and the absence of a system to track patients in need of shortterm follow-up. Other contributing factors were team-level decisionmaking problems resulting from miscommunication of urgency between providers and providers’ lack of awareness of or knowledge about a patient’s situation; and communication failures among providers, patients, and other health care team members. Our findings suggest that to support care goals in the Affordable Care Act and the National Quality Strategy, even relatively sophisticated electronic health record systems will require enhancements. At the same time, policy initiatives should support programs to implement, and perhaps reward the use of, more rigorous interprofessional teamwork principles to improve outpatient communication and coordination. T he majority of medical care in the United States is delivered in the outpatient setting. However, efforts to improve patient safety have primarily focused on the inpatient setting. A 2011 report from the American Medical Association highlighted how certain issues—such as missed and delayed diagnoses and breakdowns in communication—are widely considered to be threats to patient safety in outpatient settings but have received little empirical study. The report concludes that “we still know very little about patient safety in the ambulatory setting, and next to nothing about how to improve it.” Problems and delays in diagnosis and treatment feature prominently in prior studies of errors in outpatient care. The risk for harm in outpatient settings is substantial but is likely to be underestimated because of underreporting and other measurement-related issues (for example, some errors may introduce serious risk but not cause injury). Moreover, the fragmented nature of ambulatory care leads to unique and complex risks as patients move across different settings of care. Multiple health care providers, visits, and locations create opportunities for an array of posdoi: 10.1377/hlthaff.2013.0130