Case reports: lessons to be learnt
The following examples are based on real cases in which communication break-down in regards to responsibility for test
results compromised patient safety.
N.B. These reports were received via the bpacnz patient safety incident reporting system, which is currently inactive.
Case report 1: lung cancer diagnosis missed
A patient with a history of COPD presented at an after hours clinic, with a suspected chest infection. The patient was
advised to return the next day for a chest x-ray to exclude pneumonia. A pulmonary nodule was detected on x-ray and it
was recommended that the patient undergo a CT scan for further assessment. The result was phoned through to the Clinical
Leader at the after hours clinic by the Radiologist. The Clinical Leader sent a note to the patient’s named General Practitioner
advising that follow-up was required. The General Practitioner had not seen the patient for ten years and did not receive
the letter from the Clinical Leader, but did receive the x-ray report. The General Practitioner, after seeing the result
had been telephoned, assumed that the after hours clinician who ordered the x-ray was taking responsibility for patient
follow up. The patient changed General Practitioners shortly afterwards and the report was faxed to the new practice.
The new practice assumed the previous General Practitioner had actioned follow up. The patient presented to the new General
Practitioner one year later with a persistent cough. A repeat chest x-ray was requested and it showed a large tumour.
This case report shows how adequate follow up can be missed when one clinician assumes that another has taken action
on test results. Each of the three clinicians assumed that one of the other two was taking responsibility to follow up
the original x-ray. However, there was no successful contact between clinicians that may have resulted in earlier diagnosis
Case report 2: practice communication fail
An abnormal laboratory result for a patient was notified to a General Practitioner by phone one evening when they were
away from home for a few days. The General Practitioner decided the result needed to be actioned the next day and informed
the laboratory to fax the result to the practice as per usual procedure, with the intention it would be viewed by another
clinician the next morning.
The General Practitioner made three phone calls to the practice the next day to follow up:
- Call one – could not get through to the practice
- Call two – left a message on the lead clinician’s mobile
- Call three – left a message on the nurse’s answer phone
Upon returning to work two days later, the General Practitioner noticed the faxed result, which had been scanned by
a receptionist but not viewed by a clinician. A family member of the patient had also phoned the practice and spoken to
a nurse, but this conversation had not been properly documented. The first nurse’s phone was found not to be working and
the lead clinician had not checked their phone message. The patient was urgently admitted to hospital for treatment.
This reveals how patient follow up can be delayed when messages are missed due to breakdowns in communication. It also
highlights potential problems when the clinician who ordered the test is away from the practice when the results are received.
It shows how important it is that information is relayed directly between clinicians and other practice staff. Would a
‘handover’ prior to going on leave, to delegate responsibility for follow up to another clinician, or an electronic task
reminder in the PMS for the practice staff have changed the outcome for this patient?