title: Process of care failures in breast cancer diagnosis.
abstract: BACKGROUND
  Process of care failures may contribute to diagnostic errors in breast cancer care.
  
  
  OBJECTIVE
  To identify patient- and provider-related process of care failures in breast cancer screening and follow-up in a non-claims-based cohort.
  
  
  METHODS
  Retrospective chart review of a cohort of patients referred to two Boston cancer centers with new breast cancer diagnoses between January 1, 1999 and December 31, 2004.
  
  
  METHODS
  We identified 2,275 women who reported > or =90 days between symptom onset and breast cancer diagnosis or presentation with at least stage II disease. We then selected the 340 (14.9%) whose physicians shared an electronic medical record. We excluded 238 subjects whose records were insufficient for review, yielding a final cohort of 102 patients.
  
  
  METHODS
  None
  
  
  METHODS
  We tabulated the number and types of process of care failures and examined risk factors using bivariate analyses and multivariable Poisson regression.
  
  
  RESULTS
  Twenty-six of 102 patients experienced > or =1 process of care failure. The most common failures occurred when physicians failed to perform an adequate physical examination, when patients failed to seek care, and when diagnostic or laboratory tests were ordered but patients failed to complete them. Failures were attributed in similar numbers to provider- and patient-related factors (n = 30 vs. n = 25, respectively). Process of care failures were more likely when the patient's primary care physician was male (IRR 2.8, 95% CI 1.2 to 6.5) and when the patient was non-white (IRR 2.8, 95% CI 1.4 to 5.7).
  
  
  CONCLUSIONS
  Process failures were common in this patient cohort, with both clinicians and patients contributing to breakdowns in the diagnostic process.
authors.affiliation: Center for Patient Safety, Dana-Farber Cancer Institute, 44 Binney St., Boston, MA, 02115, USA. saul_weingart@dfci.harvard.edu
authors.forename: Saul N
authors.initials: SN
authors.lastname: Weingart
authors.forename: Mark G
authors.initials: MG
authors.lastname: Saadeh
authors.forename: Brett
authors.initials: B
authors.lastname: Simchowitz
authors.forename: Tejal K
authors.initials: TK
authors.lastname: Gandhi
authors.forename: Larissa
authors.initials: L
authors.lastname: Nekhlyudov
authors.forename: David M
authors.initials: DM
authors.lastname: Studdert
authors.forename: Ann Louise
authors.initials: AL
authors.lastname: Puopolo
authors.forename: Lawrence N
authors.initials: LN
authors.lastname: Shulman
mesh_terms: D000328:Adult; D000368:Aged; D001943:Breast Neoplasms / Q000175:diagnosis* / Q000628:therapy*; D015331:Cohort Studies; D005260:Female; D005500:Follow-Up Studies; D006282:Health Personnel / Q000592:standards; D006801:Humans; D008137:Longitudinal Studies; D008297:Male; D008875:Middle Aged; D019984:Quality Indicators, Health Care / Q000592:standards; D012189:Retrospective Studies; D017211:Treatment Failure