Failure to recognize newly identified aortic dilations in a health care system with an advanced electronic medical record.

Abstract

Concern is growing about missed test results, but data assessing their effect on patient safety are limited. To examine the frequency with which computed tomography (CT)-documented dilations of the abdominal aorta are accompanied by evidence in the electronic medical record (EMR) that a clinician recognized the abnormality. Retrospective cohort study. 2 hospitals in the Veterans Affairs Health Care System. Patients with new dilations of the abdominal aorta detected on CT performed in 2003. Radiology report and EMR evidence that the radiologist notified the clinical service, aneurysm size, and interval between CT and EMR recognition. Computed tomography scans of 4112 patients were reviewed and 440 (11%) aortic dilations were identified, of which 91 were new findings. Radiologists directly notified clinical teams about 5 (5%) new dilations. Clinical teams did not record in the EMR recognition of 53 of 91 (58%) dilations within 3 months of the CT, and 9% of these dilations were 5.5 cm or larger. The median time to recognition of aneurysm in the EMR was 237 days, and no EMR documentation existed for 16 abnormalities (29% of surviving patients) during a mean follow-up of 3.2 years. No evidence indicated that any of the aneurysms ruptured or that patient deaths resulted from the delayed follow-up. Clinicians may have recognized some aneurysms but did not document them in the EMR. Clinicians neglect to note a substantial proportion of new aortic dilations in the EMR. The findings highlight the need for better strategies to ensure documentation of follow-up of tests.