A 70-year-old healthy man presented to his primary care doctor—a third-year internal medicine resident—for routine follow-up. The resident was in his final month of training, and would leave the institution for fellowship at the completion of his residency.
After discussion, the provider sent off a prostate-specific antigen (PSA) test to screen the patient for prostate cancer. The patient's past PSA tests had always been normal. Unfortunately, this time his PSA returned markedly elevated at 83 ng/ml—a level at which cancer is a near certainty. The patient was not immediately notified as the electronic alert (via an existing electronic health record) was sent to the patient's primary care provider. However, because this provider had graduated and left the program before the alert returned, and there was no system to ensure smooth handoffs to oncoming residents, the alert went unread.
Eight months later, the patient presented with new onset low back pain. Imaging tests confirmed metastatic prostate cancer and also uncovered the missed follow-up of the elevated PSA.
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