EHR Routing Failure Leads to Delayed Cardiology Follow-Up

Description

An abnormal echocardiogram was not routed to the ordering clinician for review in the electronic health record, delaying timely cardiology follow-up and intervention before the patient experienced cardiac arrest and died.

Key Lessons

• Closed-loop test result management is essential. Abnormal diagnostic findings should be routed to, reviewed by, and acknowledged by the responsible clinician before being permanently filed.
• EHR workflows can create hidden safety risks. Routing, review, and sign-off processes require safeguards to prevent significant results from appearing complete in the record without appropriate clinical action.
• Accountability for follow-up and escalation must be clearly defined. Practices need reliable processes for test-result review, patient notification, referral placement, and timely escalation of clinically significant findings.

Clinical sequence

An adult patient with a history of hypertension and a heart murmur was seen for a routine primary care visit. Because the murmur had become more pronounced, the clinician ordered laboratory testing and an echocardiogram (EKG) and planned follow-up several months later.

The EKG showed a moderately dilated left ventricle, reduced ejection fraction, and moderate to severe global hypokinesis. The report was faxed to the practice and entered into the electronic health record (EHR), but it was not forwarded to the ordering clinician’s review queue. As a result, the report was neither reviewed nor signed off.

Several months later, the patient returned for an unrelated concern and asked about the EKG results. The ordering clinician recognized the abnormal findings and referred the patient to cardiology, but the referral was not identified as urgent.

A cardiology evaluation occurred later that month, and cardiac catheterization was scheduled shortly afterward at the patient’s preferred facility. The patient died before the procedure could be performed. Following the event, the practice implemented a policy requiring test results to be routed to the ordering physician’s queue and reviewed before being permanently filed in the EHR.

Allegation

The claim alleged a delay in diagnosis and treatment of cardiomyopathy following the failure to review and act on abnormal EKG results. Allegations included inadequate follow-up of diagnostic test results, delayed referral and intervention, and insufficient test-result tracking processes.

Disposition

The case closed with an indemnity payment in the high range ($500,00–$999,999).

Clinical Analysis

Key contributing factors included the lack of a reliable closed-loop test-result process, electronic routing and filing vulnerabilities, insufficient backup procedures for identifying unreviewed abnormal results, and missed opportunities to escalate the cardiology referral and intervention timeline. The event demonstrates how gaps in EHR workflows and result-tracking processes can allow clinically significant findings to go unaddressed. Following the event, the practice addressed a key system vulnerability by requiring test results to be routed to the ordering clinician’s queue and reviewed before being permanently filed.

Discussion Questions

1. What safeguards should be in place to ensure abnormal test results are routed to and acknowledged by the responsible clinician?
2. How should physician practices define and monitor accountability for follow-up when diagnostic results are filed electronically?
3. What criteria should prompt urgent referral or escalation when delayed recognition of an abnormal result occurs?

References/Other Resources

• CRICO: When Test Results Go Unspoken – Case study highlighting communication failures involving abnormal imaging results, delayed diagnosis, and the need for closed-loop follow-up processes.
• AHRQ PSNet: Advancing Safety with Closed-Loop Communication of Test Results – Patient-safety resource summarizing risks associated with incomplete test-result communication and strategies to improve closed-loop follow-up.
• AHRQ: Closed-Loop Diagnostics Patient Safety Learning Lab – Overview of research and interventions to improve timely follow-up of diagnostic tests, referrals, and evolving symptoms across care settings.
• ECRI: Health IT Safe Practices for Closing the Loop – Toolkit focused on reducing delayed, missed, and incorrect diagnoses through safer health IT communication, tracking, acknowledgment, and accountability practices.
• The Joint Commission: Quick Safety Issue 52: Advancing Safety with Closed-Loop Communication of Test Results – Patient-safety advisory defining closed-loop communication and recommending practices to prevent delayed or incomplete communication of abnormal results.
• ONC: SAFER Guide: Test Results Reporting and Follow-Up – Self-assessment guide for evaluating EHR-based test-result reporting and follow-up processes, organizational responsibilities, and safeguards to reduce missed or delayed follow-up.

This is a fictitious case that illustrates commonly encountered issues and is for educational purposes only. Any resemblance to real persons, living or dead, is purely coincidental.