Avoiding late-stage colorectal cancer: The outpatient safety net.

Abstract

177 Background: The Institute of Medicine report "To Err is Human" highlighted two vulnerabilities that introduce possible diagnostic errors — information overload and failure to follow up abnormal cases. The Southern California Permanente Regional Safety Net program was instituted to identify, using electonic medical records, instances where these inadvertent outpatient safety lapses may have occurred and intervene before patient harm develops. A centralized regional team catches the omission and intervenes to ensure necessary follow up care, early diagnosis, treatment monitoring, or preventing harmful interactions from medications. Methods: For colorectal cancer detection and prevention, a safety net system was already in place to ensure the prompt evaluation of a positive fecal occult blood screening test with colonoscopy. However, evaluation of late stages of colorectal cancer at presentation revealed that failure to diagnose/follow up signs of iron deficiency anemia or rectal bleeding (often attributed to hemorrhoids) were opportunities to intervene. The electronic medical record is mined for evidence of iron deficiency anemia in laboratory results or a diagnosis of rectal bleeding that was not followed by a colonoscopy in patients aged 50-75. A list of these patients is reviewed quarterly by a gastroenterologist, who contacts the primary care physician to arrange colonoscopy. Results: During the first six months of the program, 42 patients, aged 52-75, underwent colonoscopy for evaluation of either evidence of iron deficiency anemia or rectal bleeding. Polypectomies were performed in 17 patients (40%) with pathology revealing adenomas in 13 patients and one patient with a bleeding carcinoid tumor. Other findings included hyperplastic polyps, hemorrhoids, diverticular disease, colitis, ulcer, and angiodysplastic lesions. Conclusions: Using an electronic medical record system, an outpatient safety net function allows proactive identification of possible safety issues in the population, helping to avoid late stage diagnoses and adverse outcomes. This system currently encompasses other cancer screening tests, medication monitoring, avoiding harmful medication interactions, and immunizations.