Ms Q was a 32-year-old nurse practitioner (NP) working for a very busy family practice in a large city. She had been employed there for 5 years, and although she liked the work, she did not like the fact that she had to see so many patients in one day. When she was hired, she had been told that she had to get patients in and out of the examination room in about 15 minutes.

Clinicians who spent too much time with each patient or those who saw fewer patients than expected per day would be spoken to by the managing physician. Because of this, the practice sometimes felt like working in a factory to Ms Q.

One afternoon, Mrs C, one of Ms Q’s patients, showed up for an appointment. The 58-year-old woman complained of chest pain and that she had heard a crack and thought she might have injured a rib.

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Ms Q examined the patient. Mrs C was in relatively good health, with no chronic illnesses, and was not on any medication other than synthetic thyroid replacement. After evaluating the patient, Ms Q decided to send her for a chest radiograph.

“I don’t see any obvious problem,” said Ms Q to her patient, “but I’d like you to get a chest X-ray to be sure.” She handed the patient a referral, ushered her out of the exam room, and brought in the next patient.

Mrs C went for the radiograph a few days later, which revealed that she had a 1.5-cm mass in the right middle lobe of her lung. The radiologist put this information in his report, as well as his recommendation that the patient go for a CT scan, and sent the report to Ms Q’s practice.

Had the practice received the report, the office policy was to notify the clinician whose patient it was, have the clinician sign off on the results, and then file the results in the patient’s file.

However, the report never arrived at the practice, and there was no policy in place as to how to handle test results that are ordered but which never arrive.

Ms Q, who assumed she would be notified when the results came in, forgot about it entirely. The patient assumed that since she had not heard from Ms Q, the radiograph results must have been fine.

Sixteen months after her initial visit, Mrs C returned to the practice to see Ms Q. This time she complained of a cough and chest pain that had been occurring for the past few weeks. Ms Q noticed that the original chest radiograph results were not in the file, although she had a note that she had given the patient a referral.

“Did you go for that chest X-ray I ordered last time?” Ms Q asked the patient.

Mrs C looked surprised. “Yes, of course I did,” she replied. “When I didn’t hear from you, I assumed that it was all okay. Isn’t it?”

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“I’m sure it’s fine,” said Ms Q, reassuringly. “I don’t see the results here. Let’s send you for another X-ray since the problem hasn’t resolved.”

She wrote another referral for Mrs C and sent her to the radiologist.

This time the results were received by the office, and they showed a 4-cm mass in the right middle lobe. A CT scan revealed enlarged mediastinal lymph nodes.