Cases & Commentaries

Lost in the Black Hole

Commentary By Robert M. Wachter, MD

The Case

A 38-year-old married, monogamous female came to
the emergency department with aseptic
meningitis. She had a remote history of gonorrhea, no
environmental exposures, and had not taken any non-steroidal
anti-inflammatory or sulfonamide drugs. She was admitted to the
hospital and cared for by a hospitalist, who suspected that the
patient might have acute HIV and ordered a test for HIV
quantitative PCR. The test result (positive, with a viral load of
32,000 copies/mL) came back more than 1 week after the patient was
discharged, and the hospitalist noted it. However, the laboratory
indicated that the batch was "defective" and the test needed to be
rerun. The hospitalist never received the new report and, lacking a
reminder system, forgot to follow up on the result. Neither the
patient nor the primary care physician was notified that an HIV
test was pending, so neither of them followed up on this test
result. The error was first recognized 6 months later when the
hospitalist stumbled upon the original test report while cleaning
out a desk.

In fact, the patient´s aseptic meningitis
was her first manifestation of acute HIV seroconversion. Although
it was unclear whether the delayed notification had adverse
clinical consequences (the role of antiretroviral treatment during
primary HIV infection is controversial), it caused the patient
major emotional distress, delayed referral to an HIV specialist,
and raised the possibility of unprotected intercourse during the 6
months during which she was seropositive but unaware of her

The Commentary

Although continuity of care is a laudable goal,
having a single doctor manage care in all settings is nearly
impossible. Primary care physicians (PCPs) are under pressure to
see more outpatients in less time, and the average PCP now spends
relatively little time in the hospital. A growing literature has
established the value of specialized care for complex diseases or
in complex settings.(1)
Interest in patient safety and quality has catalyzed the creation
of teams (often physician-led) that can focus on improving the
systems of care in a given setting.(2)
Taken together, these forces have led to the development of the
hospitalist, to manage and coordinate inpatient care and help
improve systems of care.(3,4)
Early literature supports the premise that switching from PCP-based
to hospitalist-based inpatient care can improve efficiency,
quality, and teaching.(5-8)

Several questions about the hospitalist model
still must be answered.(9) One
is the impact of the "purposeful discontinuity" that the model
introduces between inpatient and outpatient worlds. This case, in
which a critical laboratory test result fell into the “black
hole” that often separates a hospital stay from the follow-up
setting, highlights the problem. A recent study found that nearly
one in five patients experienced an adverse event
during the transition from hospital to home; two-thirds could have
been prevented or ameliorated with better bridging.(10) A simple follow-up call by a pharmacist can prevent
some post-discharge adverse events.(11)
However, few institutions have such a system, in part because it is
neither reimbursed nor emphasized. Many providers and health care
organizations lack any organized approach to preventing
transitional errors. Such approaches involve three areas: clear
delineation of roles and responsibilities, better methods for
transmitting verbal data, and information technology.

The first issue is the clear delineation of roles
and responsibilities. Malpractice law, mostly drawn from
transitions in Emergency Medicine, places duties on both the
hospital-based physician and the PCP.(12) Practically, though, saying that both the hospitalist
and the PCP are responsible after discharge creates false
redundancy: because neither is unambiguously responsible, too often
both will assume that the other will follow-up. I believe that the
hospitalist does maintain responsibility for ensuring that critical
laboratory tests drawn on his watch are followed-up, either by
doing it himself or by confirming that the PCP accepts this
responsibility. In this case, the hospitalist did neither—an
error of omission.

The role of a third party—the laboratory
itself—has been underemphasized. Courts have held that
radiologists have an obligation to ensure that critical findings
(such as abnormal mammograms) are transmitted to the relevant
provider (13),
and one could make the same argument for key lab studies such as
positive HIV tests. Interestingly, this hospitalist´s
(appropriate) decision to run a quantitative HIV PCR may have
facilitated this error by exposing another hole in the Swiss Cheese of our
data transmission "system." Had the usual HIV ELISA screening assay
been run (whose results return "positive" or "negative" for HIV),
the lab probably would have made sure that a positive result
reached the correct physician. The quantitative PCR test for HIV
viral load, however, is usually used to monitor response to therapy
in patients with known HIV. Thus, clinical labs generally do not
notify individuals of the test´s results, lest they be
calling incessantly. This case illustrates the one situation in
which the test is used diagnostically rather than to follow
therapeutic response: in acute HIV infection, the ELISA HIV test
may be falsely negative (it may take weeks after seroconversion to
turn positive) and the HIV PCR is the more sensitive
test.(14) In
fact, the reporter of this case mentioned that the hospital´s
order form for HIV PCR now (as a result of this case) queries
whether the test is being sent to diagnose HIV or follow its
course. If the former, the lab treats the result as it would any
new diagnosis of HIV and contacts the responsible physician. This
modification represents an admirable example of a systems change in
response to an error.

In addition to follow-up, the mechanisms for
passing a baton must become more robust. One study found that being
covered by another physician was a more powerful predictor of
hospital complications and errors than was the severity of a
patient´s illness.(15)
The same researchers instituted a standardized computerized
sign-out system, and the error rate fell by two-thirds.(16) By
increasing the number of handoffs, new housestaff work-hour
restrictions mandated by the Accreditation Council on Graduate
Medical Education (ACGME) may have the unintended effect of
increasing medical errors unless methods can be found to
prevent the degradation of information during transfers of
care.(17) In
our department, we recently initiated a computerized sign-out
system in response to this increase in handoffs.

Although computerization of information transfer
is part of the answer, verbal handoffs will always occur, and can
often be "sloppy." Other fields that transfer critical information
verbally have developed methods to minimize the risks. For example,
workers in commercial aviation and the military read-back key
transmissions and use standard language and alphabets (such as the
NATO system of "Alpha-Bravo-Charlie-Delta") to minimize
misunderstandings. Restaurants may take verbal handoffs more
seriously than hospitals: you are more likely to hear "let me read
your order back to you" when you call a restaurant for takeout than
when you call a colleague to sign out a patient or to issue a
verbal order.(18)

Although it would be easy to blame this error on
a forgetful hospitalist, preventing transitional errors requires
that health care systems put attention and resources into
preventing such fumbles. Until systems become more robust,
physicians will need to develop their own micro-systems for
following up on key tests (such as paper, PDA, or computer-based
"tickler" systems), using these prompts to remind themselves to
contact both patients and physicians. Some large primary care,
hospitalist, and emergency department groups have created methods
to follow-up test results, such as designating a single responsible
physician, nurse, or clerk to check all lab and x-ray studies and
ensure that the results reach the appropriate provider.

The days in which a single physician can be
responsible for patients in all settings will live on only in
Marcus Welby reruns. Patients will constantly be moving from
setting to setting and from provider to provider. This places a
great responsibility on individual providers and health care
systems to ensure that handoffs aren’t dropped. As it stands
now, if our health care system was an NFL team, we would lead the
league in fumbles. We can and must do better.

Take-Home Points

  • Handoffs are the price we pay for
    the benefits of specialized care.
  • The
    hospitalist model is growing rapidly, but has the side effect of
    creating another transition of care at hospital
  • Improving care across
    transitions will depend on clearly delineating responsible parties,
    creating standard methods to ensure accurate transmission of verbal
    information, and using information
  • Standard information transfer protocols, such as
    reminder systems to cue providers to check tests, mandating that
    laboratories or radiology departments contact providers about
    critical lab values, and read-backs of key verbal information, have
    been used to great effect in other industries and should be adopted
    in health care to prevent transitional

Robert M. Wachter,
Professor and Associate Chair, Department of Medicine
University of California, San Francisco
Chief of the Medical Service, UCSF Medical Center
Editor, AHRQ WebM&M


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