Presenter: Marjie Grazi Harbrecht, MD, Risk Management and Medical Consultant; Medical/Executive Director
Institution: Colorado Clinical Guidelines Collaborative
Introduction: Delays in diagnosis of breast cancer are not only the most prevalent and second most expensive reason for a malpractice claim against a physician in the United States they are an important patient safety issue. When a delay occurs, it is usually devastating for both the patient and clinician involved. To evaluate this issue further, two studies were conducted. In the first study, closed claims from a large malpractice insurance carrier were reviewed to identify why the delays were occurring. Factors included management/judgment issues, misread mammograms, tracking and reminder issues, communication issues and documentation issues. For example, in one case, a 29-year-old female presented with a breast mass that was not biopsied initially because she was “low risk” – eight months later she was diagnosed with breast cancer. In another case, an abnormal mammogram report was not discovered until months later when the patient presented with metastatic breast cancer. To address the issues, guidelines were developed and educational seminars have been given to clinicians, including residents, to increase awareness and help avoid diagnostic delays. The materials are also being converted to an interactive CD-ROM and Web-based format, which can be integrated into residency or other medical training programs.
As the next step, The Breast Evaluation System (BREST) was developed as an implementation tool to help clinicians integrate key elements of the guidelines into daily practice and address the various issues identified as leading to delays. The system contains flow sheets for patient visits, patient and physician education materials, a tracking and reminder system, several pre-written letters and other tools to encourage a systematic approach to breast management, improve patient care and decrease risk for physicians. The BREST System was evaluated in a second small pilot study and demonstrated significant differences in patient follow-up procedures, documentation of care, communication with patients and most importantly, whether physicians resolved a breast problem in a timely manner according to the guidelines. Further investigation is being planned to evaluate these findings on a larger scale and adapt the tools and techniques to a broader range of diseases and conditions.
As many studies have demonstrated, the most challenging part of any guideline program is to affect change at the practice level. This becomes ever more difficult for physicians faced with overwhelming amounts of medical information, increasing administrative burdens and time constraints. It will be an important part of any medical school and residency training program not only to incorporate good risk management principles into educational programs, but also to provide the tools and systematic approaches needed to incorporate those principles into every day practice.
