Original Article

Journal of General Internal Medicine

, Volume 24, Issue 6, pp 702-709

First online:

Process of Care Failures in Breast Cancer Diagnosis

  • Saul N. WeingartAffiliated withCenter for Patient Safety, Dana-Farber Cancer InstituteHarvard Medical School Email author 
  • , Mark G. SaadehAffiliated withCenter for Patient Safety, Dana-Farber Cancer Institute
  • , Brett SimchowitzAffiliated withCenter for Patient Safety, Dana-Farber Cancer Institute
  • , Tejal K. GandhiAffiliated withHarvard Medical SchoolDivision of General Internal Medicine, Brigham and Women’s Hospital
  • , Larissa NekhlyudovAffiliated withHarvard Medical SchoolDepartment of Ambulatory Care and Prevention, Harvard Medical SchoolHarvard Vanguard Medical Associates
  • , David M. StuddertAffiliated withMelbourne Law School, University of Melbourne
  • , Ann Louise PuopoloAffiliated withRisk Management Foundation of the Harvard Medical Institutions
  • , Lawrence N. ShulmanAffiliated withCenter for Patient Safety, Dana-Farber Cancer InstituteHarvard Medical School

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Process of care failures may contribute to diagnostic errors in breast cancer care.


To identify patient- and provider-related process of care failures in breast cancer screening and follow-up in a non-claims-based cohort.


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.


We identified 2,275 women who reported ≥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.




We tabulated the number and types of process of care failures and examined risk factors using bivariate analyses and multivariable Poisson regression.


Twenty-six of 102 patients experienced ≥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).


Process failures were common in this patient cohort, with both clinicians and patients contributing to breakdowns in the diagnostic process.


breast cancer diagnostic errors medical errors quality of health care