@article{7317, author = {Ellie Grossman and Russell S. Phillips and Saul N. Weingart}, title = {Performance of a fail-safe system to follow up abnormal mammograms in primary care.}, abstract = {

OBJECTIVES: Missed and delayed breast cancer diagnoses are major sources of potential harm to patients and medical malpractice liability in the United States. Follow-up of abnormal mammogram results is an essential but challenging component of safe breast care. To explore the value of an inexpensive method to follow up abnormal test results, we examined a paper-based fail-safe system.

METHODS: We examined a fail-safe system used to follow up abnormal mammograms at a primary care practice at an urban teaching hospital. We analyzed all abnormal mammogram reports and clinicians' responses to follow-up reminders. We characterized potential lapses identified in this system and used regression models to identify patient, provider, and test result characteristics associated with such lapses.

RESULTS: Clinicians responded to fail-safe reminders for 92% of 948 abnormal mammograms. Clinicians reported that they were unaware of the abnormal result in 8% of cases and that there was no follow-up plan in place for 3% of cases. Clinicians with more years of experience were more likely to be aware of the abnormal result (odds of being unaware per incremental year in practice, 0.92; 95% confidence interval, 0.88-0.97) and were more likely to have a follow-up plan.

CONCLUSIONS: A paper-based fail-safe system for abnormal mammograms is feasible in a primary care practice. However, special care is warranted to ensure full clinician adherence and address staff transitions and trainee-related issues.

}, year = {2010}, journal = {J Patient Saf}, volume = {6}, pages = {172-179}, month = {09/2010}, issn = {1549-8425}, language = {eng}, }