Practice dilemma - A high PSA result is missed

The dilemma: An elderly patient comes to see you in clinic for back pain and worsening lower urinary tract symptoms. On looking through his notes you notice an abnormally high PSA result was missed a few months ago during a well man clinic at the practice. He subsequently asks for his blood test results, as he hadn't been informed of the results. How should you handle the situation?

It is important to give the patient a full account of the investigation and outcomes, along with lessons learned for future practice
It is important to give the patient a full account of the investigation and outcomes, along with lessons learned for future practice

A GP's response

Dr Louise Warburton is a GP in Ironbridge, Shropshire
This is a potentially difficult situation. The patient could have prostatic cancer that has been overlooked.

At this initial consultation I would take a history of his symptoms and proceed to an abdominal examination and a rectal examination to assess the size of his prostate gland.

I would tell him about the previous PSA result as it is best to be honest. An abnormally high PSA does not automatically mean that he has prostate cancer. The PSA can be raised in chronic prostatitis for example.

However, patients with high PSA results should be referred for urgent assessment and I would explain to the patient that he needed an urgent referral.

I would also explain that he could have prostatic cancer. A prostatic ultrasound and biopsy would be required first.

He may well be angry about the missed result. I would apologise on behalf of the practice and promise that the mistake would be thoroughly investigated.

If he wished to make a complaint I would offer him advice on how to do so.

After the consultation I would complete an incident report form and tell the practice manager about an anticipated complaint. The missed result would then be discussed at a significant event meeting and procedures put in place to prevent it happening again. The person(s) responsible would be asked to comment on the events.

A review of how the practice deals with normal and abnormal results would also be relevant.

The patient may not make a complaint. I find that if a full explanation and apology is offered, patients often understand and forgive the mistake, especially if the practice has uncovered a flaw in its systems and something positive is done about it for the future.

A medico-legal view

Dr Angelique Mastihi is a medico-legal adviser for the Medical Protection Society
When an error comes to light it is important that the patient be informed, an apology given and that steps are taken to ensure that any further harm is minimised. In this case the gentleman clearly now also needs further investigation.

Once steps have been taken to ensure the patient's clinical condition is managed correctly, the incident will need to be investigated to establish what happened, what lessons can be learned and that which can be taken to reduce the likelihood of the error recurring.

When investigating clinical incidents it is important not to make assumptions. Guidance on methodology can be found on the National Patient Safety Agency website or from your local clinical risk or governance team.

The patient should be kept fully informed of the investigation and outcome. He should be informed that an investigation into the incident will be carried out and updated as to any findings, along with lessons learned and actions.

Unfortunately, results can easily be missed. It is important that the practice has an effective system of reviewing and managing results, which can be audited, to ensure that abnormal results are not inadvertently filed.

Practices should also consider having a system that enables the tracking of investigations, which will flag up any incidents where the investigation has not taken place, or the result has not been received or acted upon.

A patient's opinion

Elizabeth Brain is a lay member of the RCGP Patient Partnership Group
You should first apologise to the patient for the oversight and say that you will ensure that the reasons for the delay are fully investigated and that they will be explained to him in due course.

However, you should emphasise to him that the first priority is to obtain an up-to-date set of blood test results to determine the current state of his health in order that the best course of action can be carried out.

He should be requested to return within a few days for the results.

As this represents a significant event you should bring the matter to the attention of the practice manager and ensure an investigation is carried out into why the patient's well man clinic results were not brought to your attention at the time. The subsequent lessons should be recorded and the relevant processes rectified to prevent a recurrence.

Any necessary disciplinary action should be instigated. The most important issue, apart from resolving the patient's situation, is to ensure that the practice acts with professional integrity.

On the patient's return for the results, you should give him a full account of the circumstances that led to a lack of follow up on his previous blood test results and say that corrective actions are in place to prevent a recurrence within the practice.

Finally, you should assure him of your due diligence in helping him in any way you can.

That would be the very least that you owed him.

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