Failure to Recognize Newly Identified Aortic Dilations in a Health Care System With an Advanced Electronic Medical Record

  1. Jennifer R.S. Gordon, BS;
  2. Terry Wahls, MD, MBA;
  3. Ruth C. Carlos, MD, MS;
  4. Iraklis I. Pipinos, MD;
  5. Gary E. Rosenthal, MD; and
  6. Peter Cram, MD, MBA
  1. From the University of Iowa Carver College of Medicine and Iowa City Veterans Administration Medical Center, Iowa City, Iowa; University of Michigan College of Medicine, Ann Arbor, Michigan; and University of Nebraska Medical Center, Omaha, Nebraska.

    Abstract

    Background: Concern is growing about missed test results, but data assessing their effect on patient safety are limited.

    Objective: 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.

    Design: Retrospective cohort study.

    Setting: 2 hospitals in the Veterans Affairs Health Care System.

    Patients: Patients with new dilations of the abdominal aorta detected on CT performed in 2003.

    Measurements: Radiology report and EMR evidence that the radiologist notified the clinical service, aneurysm size, and interval between CT and EMR recognition.

    Results: 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.

    Limitation: Clinicians may have recognized some aneurysms but did not document them in the EMR.

    Conclusion: 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.

    Primary Funding Source: National Institutes of Health.

    Article and Author Information

    • Disclaimer: The views expressed in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs.

    • Grant Support: Drs. Cram, Wahls, and Rosenthal have appointments in the Center for Research in the Implementation of Innovative Strategies in Practice at the Iowa City Veterans Affairs Medical Center, which is funded through the Department of Veterans Affairs, Veterans Health Administration, Health Services Research and Development Service. Dr. Cram is supported by a K23 career development award (RR01997201) from the National Center for Research Resources, National Institutes of Health and the Robert Wood Johnson Physician Faculty Scholars Program. Dr. Carlos is supported by a K07 career development award (CA108664) from the National Cancer Institute, National Institutes of Health. Dr. Pipinos is supported by a KO8 career development award (1 K08 HL079967-01) from the National Heart, Lung, and Blood Institute, National Institutes of Health, and by the William J. von Liebig Award from the American Vascular Association.

    • Potential Financial Conflicts of Interest: None disclosed.

    • Reproducible Research Statement: Study protocol and statistical code: Available from Dr. Cram (e-mail, peter-cram{at}uiowa.edu). Data set: Not available.

    • Requests for Single Reprints: Peter Cram, MD, MBA, Division of General Medicine, University of Iowa Carver College of Medicine, Iowa City Veterans Affairs Medical Center, Mail Stop 152, Iowa City, IA 52242; e-mail, peter-cram{at}uiowa.edu.

    • Current Author Addresses: Ms. Gordon: University of Iowa Carver College of Medicine, 200 Hawkins Drive, Iowa City, IA 52242.

    • Drs. Wahls and Cram: Division of General Medicine, University of Iowa Carver College of Medicine, Iowa City Veterans Affairs Medical Center, Mail Stop 152, Iowa City, IA 52246.

    • Dr. Carlos: Department of Radiology, University of Michigan, 1500 East Medical Center Drive, Ann Arbor, MI 48109-0030.

    • Dr. Pipinos: Department of Surgery, University of Nebraska Medical Center, Omaha, NE 68198-3280.

    • Dr. Rosenthal: Center for Research in the Implementation of Innovative Strategies in Practice, Division of General Internal Medicine, University of Iowa Hospitals and Clinics, SE618 GH, 200 Hawkins Drive, Iowa City, IA 52242.

    • Author Contributions: Conception and design: T. Wahls, R.C. Carlos, P. Cram.

    • Analysis and interpretation of the data: J.R. Gordon, I.I. Pipinos, P. Cram.

    • Drafting of the article: J.R. Gordon, T. Wahls, P. Cram.

    • Critical revision of the article for important intellectual content: R.C. Carlos, I.I. Pipinos, G.E. Rosenthal, P. Cram.

    • Final approval of the article: J.R. Gordon, R.C. Carlos, I.I. Pipinos, P. Cram.

    • Provision of study materials or patients: I.I. Pipinos, P. Cram.

    • Statistical expertise: P. Cram.

    • Obtaining of funding: P. Cram.

    • Administrative, technical, or logistic support: G.E. Rosenthal.

    • Collection and assembly of data: J.R. Gordon, P. Cram.

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    1. Ann Intern Med July 7, 2009 vol. 151 no. 1 21-27
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