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Don’t Be Misled by Different Test Report Formats

Faxed reports, portals, electronically transmitted reports — physicians have had to adapt to a number of different formats in which they receive their reports. The various formats used in modern reports, plus the longstanding scourge of confirmation bias, make paying close attention to all such communications vital to patient safety.

Dr. GP, a general practitioner, had been caring for his patient for a variety of issues for 27 years prior to the 62-year-old gentleman undergoing a cholecystectomy. In a copy of the report that Dr. GP received via fax, the surgeon for the procedure included in his post-op diagnosis “cirrhosis of the liver,” and noted in his operative report that the liver was mildly cirrhotic. Dr. GP did not receive a copy of a lab test ordered by the surgeon two days post-op which showed the patient as positive/abnormal for Hepatitis B.

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When Dr. GP saw his patent three days following the surgery, the physician’s assessment included “elevated liver enzymes, pending workup.” Enzymes from the lab ordered by Dr. GP were only slightly elevated, though labs ordered by Dr. GP 10 years earlier showed higher values. Results for a hepatitis panel ordered by Dr. GP gave the first result as “HBsAg Screen: positive,” which meant that the surface antigen for Hepatitis B was positive. On the following lines, the report listed negative findings for Hepatitis A and for Hepatitis B core. The result for Hepatitis C showed a value within the numerical range. Several days later, however, Dr. GP telephoned his patient to advise him that he was positive for Hepatitis A and that no further action was needed.

Dr. GP saw the patient the next month to follow up on the labs. The assessment included elevated liver enzymes, improving, but the chart made no mention of the positive Hepatitis B test result, nor was any mention included regarding the cholecystectomy surgeon’s post-op diagnosis of “cirrhosis of the liver.”

Though lab tests ordered by Dr. GP 18 months later included elevated liver enzymes, Dr. GP charted his call to the patient as relaying “stable lab” results with low Vitamin D and the need for a flu vaccine. Labs taken another year hence also showed elevated liver enzymes plus decreased platelets, though the chart reflects Dr. GP’s call to his patient reported “stable lab” results and the need for a flu vaccine.

The next year, the patient was seen in the emergency room for bloody urine and an abdominal CT showed cirrhosis of the liver. When the patient saw Dr. GP for the final time after that episode, Dr. GP referred him to a gastroenterologist. The next month, the patient was admitted to the hospital after vomiting blood. The GI’s assessment was gastrointestinal bleed, peptic ulcer disease versus cirrhosis versus esophagitis versus upper gastrointestinal malignancy versus varices. The patient signed out against medical advice with discharge diagnoses that included hematemesis, status post EGD, cirrhosis, and liver mass. The patient visited another hospital and a week later, a hepatologist diagnosis probable hepatocellular carcinoma, Hepatitis B, cirrhosis, and portal vein thrombosis and recommended immediate viral therapy with transplantation evaluation.

Following several months of infusion therapy, the patient was readmitted with severe abdominal pain, treated with morphine, and placed on DNR. He was discharged home for hospice care and died one week later. The death certificate lists the cause of death as cardiac arrest and liver cancer. A lawsuit against Dr. GP initiated by the patient’s family was resolved informally.

Viewing Dr. GP’s actions on the various reports, it may be relevant that the physician was converting the office to electronic medical records from paper documents. Further, the lab report’s listing of the Hepatitis B surface result first — where a physician may be accustomed to seeing the Hepatitis A report — demonstrates the need to assume nothing (and perhaps take a “time out”) when receiving a report in an unfamiliar format.

A physician who misses findings in a written report also raises the specter of confirmation bias, a phenomenon that leads people to see or hear what they expect to see or hear, regardless of the actual information. According to healthcare risk managers, confirmation bias is a real threat to patient safety if not overcome.  

Gordon Ownby is CAP’s General Counsel. Questions or comments related to “Case of the Month” should be directed to