The Joint Commission Journal on Quality and Patient Safety
Delayed Workup of Rectal Bleeding in Adult Primary Care: Examining Process-of-Care Failures
Section snippets
Setting
This analysis of process-of-care errors is part of a larger study of the workup of rectal bleeding performed at 10 adult primary care practices selected from among practices affiliated with three Boston-based academic medical centers and a large multispecialty group practice. Study sites included the hospital-based teaching practice at each hospital. To streamline site recruitment and simplify data collection, the study team selected at random and enrolled a subset of community practices from
Patient Characteristics
The sociodemographic, clinical, and practice characteristics of the 438 members of the study cohort are shown in Table 1. Subjects' mean age was 56, 19% were nonwhite, and 10% were Hispanic. English was the preferred language for most (92%) respondents. About one quarter lived in neighborhoods with a mean income below the US average, and 16% had Medicaid or were uninsured. A family history of colorectal cancer or colon polyps was present in 14% of subjects, 32% had a previous episode of rectal
Discussion
In this retrospective review of 438 patients cared for at 10 Boston adult primary care practices, 1 in 4 patients experienced a process-of-care failure in the workup of rectal bleeding. The most common problems included failure to elicit a complete family history, to perform an adequate physical examination, or to order, perform, or interpret a diagnostic test. Patients' behavior often contributed to process failures. Failure to order or perform diagnostic or laboratory tests and failure to
Summary
Process-of-care failures occurred frequently among adult primary care patients with rectal bleeding and were associated with overall fair or poor quality. Educating practitioners and creating office-based systems to ensure adequate history taking, physical examination, and processes for ordering, performing, and interpreting diagnostic tests are needed to improve the quality of care.
Conflicts of Interest
All authors report no conflicts of interest.
Saul N. Weingart, MD, PhD, is Chief Medical Officer, Tufts Medical Center, Boston, and Professor of Medicine, Tufts University School of Medicine, Boston.
References (44)
- et al.
Overconfidence as a cause of diagnostic error in medicine
Am J Med
(2008) Taking steps towards a safer future: measures to promote timely and accurate medical diagnosis
Am J Med
(2008)Doctor, what's wrong with me? Factors that delay the diagnosis of colorectal cancer
Patient Educ Couns
(2011)Relationship of diagnostic and therapeutic delay with survival in colorectal cancer: a review
Eur J Cancer
(2007)Lack of association between diagnostic and therapeutic delay and stage of colorectal cancer
Eur J Cancer
(2008)Diagnostic interval and mortality in colorectal cancer: u-shaped association demonstrated for three different datasets
J Clin Epidemiol
(2012)- et al.
The frequency of diagnostic errors in outpatient care: estimations from three large observational studies involving US adult populations
BMJ Qual Saf
(2014) Patient record review of the incidence, consequences, and causes of diagnostic adverse events
Arch Intern Med
(2010)Improving Diagnosis in Health Care
(2015)Learning from malpractice claims about negligent, adverse events in primary care in the United States
Qual Saf Health Care
(2004)
Missed and delayed diagnoses in the ambulatory setting: a study of closed malpractice claims
Ann Intern Med
Primary care closed claims experience of Massachusetts malpractice insurers
JAMA Intern Med
Diagnosing diagnostic errors: Lessons from a multi-institutional collaborative project
How Doctors Think
The importance of cognitive errors in diagnosis and strategies to minimize them
Acad Med
Cognitive errors and logistical breakdowns contributing to missed and delayed diagnoses of breast and colorectal cancers: a process analysis of closed malpractice claims
J Gen Intern Med
Process of care failures in breast cancer diagnosis
J Gen Intern Med
Performance of a fail-safe system to follow up abnormal mammograms in primary care
J Patient Saf
Diagnostic delay in symptomatic colorectal cancer
Cancer
Causes of late diagnosis in cases of colorectal cancer seen in a district general hospital over a 2-year period
Ann R Coll Surg Engl
Delayed treatment for rectal cancer
Dis Colon Rectum
Cited by (14)
AGA White Paper: Roadmap for the Future of Colorectal Cancer Screening in the United States
2020, Clinical Gastroenterology and HepatologyCitation Excerpt :Less than 40% of individuals with a family history of CRC have discussed this information with their health care provider.63 Family history often is not obtained owing to a lack of patient awareness and the provider’s limited ability to derive and record the information.63–65 Currently, the burden of ensuring accuracy of family history typically is placed on providers at the time of clinical visits.
Racial Disparities in Incidence of Young-Onset Colorectal Cancer and Patient Survival
2019, GastroenterologyCitation Excerpt :Although we know little about indications for colonoscopy in younger adults, or differences in receipt by race, our prior work showed increases in colonoscopy use that parallel incidence of young-onset CRC,7 which could explain increasing rates of local disease. Others have suggested unrecognized symptoms,30 such as rectal bleeding,31 contribute to delays in presentation and increasing rates of late-stage disease. Prior studies also have shown racial differences in colon cancer survival are concentrated in younger (vs older) adults,5,32–35 even after adjusting for confounders, such as treatment receipt.5,32–36
Electronic Triggers to Identify Delays in Follow-Up of Mammography: Harnessing the Power of Big Data in Health Care
2018, Journal of the American College of RadiologyCitation Excerpt :Approximately 8% of high-risk abnormal imaging test results, including results suggestive of breast cancer, fail to receive timely follow-up diagnostic evaluation [7-13]. Missed abnormal findings lead to disease progression and potentially poorer clinical outcomes [14-16]. We recently developed electronic “triggers” that offer a pragmatic and efficient method for detecting diagnostic delays [17-19].
Improving diagnostic safety in primary care by unlocking digital data
2017, Joint Commission Journal on Quality and Patient SafetyRacial and Ethnic Differences in Elective Versus Emergency Surgery for Colorectal Cancer
2023, Annals of SurgeryCompletion Rates and Timeliness of Diagnostic Colonoscopies for Rectal Bleeding in Primary Care
2023, Journal of General Internal Medicine
Saul N. Weingart, MD, PhD, is Chief Medical Officer, Tufts Medical Center, Boston, and Professor of Medicine, Tufts University School of Medicine, Boston.
Elena M. Stoffel, MD, MPH, is a Gastroenterologist and Director, Cancer Genetics Clinic, University of Michigan Health System, Ann Arbor.
Daniel C. Chung, MD, is Associate Professor of Medicine, Harvard Medical School, Boston, and Clinical Chief, Gastrointestinal Unit, Massachusetts General Hospital, Boston.
Thomas D. Sequist, MD, is Chief Quality and Safety Officer, Partners HealthCare System, Boston, and Associate Professor of Medicine and Health Care Policy, Harvard Medical School and Brigham and Women's Hospital.
Ruth L. Lederman, MPH, is Survey Manager, Survey Data Management Core, Dana-Farber Cancer Institute, Boston.
Stephen R. Pelletier, PhD, is Senior Project Manager, Center for Evaluation, Harvard Medical School, Boston.
Helen M. Shields, MD, is Professor of Medicine, Harvard Medical School, and Associate Chief, Division of Medical Communications, Brigham and Women's Hospital.