Managing Test Results

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Vials of blood

The fourth installment in our Complaints Data series: Test Result Management

What type of complaints does the College receive about physicians? Are certain specialties more likely to receive a particular complaint? In this series, we take a closer look at our recent data to provide you with a window into the type of issues that come before the College’s Inquiries, Complaints and Reports Committee.

Each year in Ontario, physicians order millions of tests for their patients. Most of the time, everything goes smoothly — physicians order tests, they receive the results and they decide what, if any, treatment decisions are needed. Of course, sometimes there are breakdowns in this process which can impact patients in significant ways and physicians will need to have processes in place that enable them to act appropriately when a clinically significant result comes in that require some action.

Let’s take a look at the case of Sean Stevens (a pseudonym) who had a clinically significant PSA result, but whose care was delayed as a result of the result not being communicated to him in a timely manner.

Mr. Stevens, a middle-aged man, visited his GP to have a rash on his leg examined and undergo routine bloodwork. After reviewing the risks and benefits of PSA screening with his doctor, he agreed to have a PSA test, and one was obtained at that visit. During the visit, Mr. Stevens, who has a family history of prostate cancer, asked for a digital rectal exam (DRE). The doctor advised him to make a follow up appointment for the DRE. 

It was only when Mr. Stevens returned to the office 13 weeks later for the DRE that he learned his PSA test was abnormal at 10.8ng/mL. When his doctor performed the exam, a fibrous nodule was found. A month later, Mr. Stevens was diagnosed with an adenocarcinoma of the prostate with a Gleason score of 8 and he underwent a radical prostatectomy. 

“From the time of my being aware of the PSA results to the time I heard about the pathology report, I was plagued with the thought that the delay in notification could have resulted in spread outside the prostate gland,” said Mr. Stevens.  

“Ensuring that you have a  process in place that helps you identify clinically significant results is critical in ensuring patient safety”

The College’s Inquiries, Complaints and Reports Committee (ICRC) agreed that Mr. Stevens had a legitimate concern about not being contacted in a timely manner and the panel members advised the doctor to improve his office management practices, including ensuring that patient contact information is up-to-date and a system for tracking incoming lab reports be put in place. 

Dr. Keith Hay, a CPSO Medical Advisor, and a family physician, urges doctors to be familiar with the expectations in the College’s Managing Tests policy. “Ensuring you have a process in place that helps you identify clinically significant results is critical in ensuring patient safety,” he said.

CPSO’s Managing Tests policy sets out the expectation that physicians have an effective test results management system that enables them to effectively communicate test results to patients and take clinically appropriate actions. This includes making sure there is a record of any test that’s been ordered, the results have been received and reviewed, and the patient has been informed of any clinically significant test results.

Engaging patients in their own care will strengthen follow-up systems. Discussing why an investigative test has been ordered allows patients to recognize its importance to their clinical situation.

Each year, the ICRC receives a number of complaints from patients who did not receive a timely diagnosis on an illness.

“The common thread amongst these complaints is that it appears physicians either did not have a system in place to manage test results or the system they had failed in some way,” said Dr. Hay.

The College recently conducted a retrospective analysis of closed investigation files related to test results management concerns, with a decision issued between January 2013 and December 2020. In order to be included in the review, the files had to identify an issue with test results management that was addressed by the ICRC.

The review consisted of 1,873 files involving 1,678 physicians. Ninety-one percent (1,526) of the doctors named in the files received one complaint related to test results management, whereas 9 percent (152) received two or more during the period of review.

In 48 percent (893) of files, communicating the test results with the patient or the patient’s health care professionals was identified as a concern. Thirty-one percent (585) were due to an inappropriate response, such as not providing follow-up care for an abnormal test result or other matters. Interpretation of the test results made up 28 percent (523) of test result issues identified. “The stakes can be high,” said Dr. Hay, noting that 12 percent (225) of the files involved a malignant neoplasm, “so it is imperative that all physicians foster a culture of safety in their offices.”

Infographic of complaints related to managing tests

Accessible summary

Read other articles in our complaints data series.