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

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.