Failure to recognize newly identified aortic dilations in a health care system with an advanced electronic medical record

Ann Intern Med. 2009 Jul 7;151(1):21-7, W5. doi: 10.7326/0003-4819-151-1-200907070-00005.


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.

Publication types

  • Multicenter Study
  • Research Support, N.I.H., Extramural
  • Research Support, Non-U.S. Gov't
  • Research Support, U.S. Gov't, Non-P.H.S.

MeSH terms

  • Aged
  • Aged, 80 and over
  • Aortic Aneurysm, Abdominal / diagnostic imaging*
  • Cohort Studies
  • Dilatation, Pathologic / diagnostic imaging
  • Documentation
  • Female
  • Humans
  • Kaplan-Meier Estimate
  • Male
  • Medical Records Systems, Computerized / standards*
  • Middle Aged
  • Retrospective Studies
  • Time Factors
  • Tomography, X-Ray Computed*