Diagnostic failures, or diagnoses that are delayed or in error, are an increasingly popular topic of research in patient safety. While some researchers have focused on the role of doctors  are there flaws in the way they think? are “gut reactions” reliable?  others have looked at the steps involved in care, or the process of care. What has emerged most recently from this latter group of studies is that diagnostic failures are often due to missed steps, so-called “process of care lapses,” that stem from both doctors and patients.

In the June issue of The Journal of General Internal Medicine, for example, investigators from Harvard Medical School studied the records of over 100 women with breast cancer diagnosed late or at advanced stages and found that roughly a quarter of patients had experienced process of care lapses. Examples of such lapses included inadequate physical exams, delayed physician involvement and incomplete diagnostic and laboratory tests. But while the investigators discovered that nearly 20 percent of the women were missing as many as two or more steps in their care, they also found that doctors and patients contributed equally to the resulting diagnostic failures.

“Clearly we found that about half of the process failures were due to something the patient did,” said Dr. Saul N. Weingart, lead author of the study and a practicing internist and vice-president of Quality Improvement and Patient Safety at the Dana-Farber Cancer Institute in Boston. “These patients missed their mammogram appointments or never went to see the specialists their primary care physicians had recommended.”

To address these lapses, experts in the field of patient safety like Dr. Weingart have proposed a variety of strategies to strengthen patient follow-up. One strategy that many physicians already use in one form or another is a “tickler system,” electronic or paper reminders to check that diagnostic testing or referrals are completed. Other ways include implementing a type of technology that allows physicians to check specific tests across their entire practice, or panel, on a monthly basis. With “the push of a button,” a doctor can see which patients have not yet followed through, for example, on their mammogram appointments.

And perhaps just as important as any technological change is one that involves transforming deep-rooted practice patterns. “It’s not part of practices now,” Dr. Weingart said, “but you can imagine creating an expectation among the medical community where if patients don’t go, the referring doctors or practices will notify you.”

But there are hidden obstacles in care as well. When Dr. Weingart and his co-investigators looked more closely at the group of individuals who had experienced lapses, they found that many were patients who were particularly vulnerable: they were minorities, possessed less education and came from challenging socioeconomic backgrounds, all of which contributed to practical obstacles or poor health literacy.

These findings “suggest that there are some intangible barriers,” Dr. Weingart remarked. “Perhaps these patients don’t know how to access care, need an interpreter, live farther away, or may be overwhelmed by family responsibilities. All of these factors are distractions for a patient and make getting care all that much harder.”