Journal of General Internal Medicine

, Volume 24, Issue 6, pp 702–709

Process of Care Failures in Breast Cancer Diagnosis


    • Center for Patient SafetyDana-Farber Cancer Institute
    • Harvard Medical School
  • Mark G. Saadeh
    • Center for Patient SafetyDana-Farber Cancer Institute
  • Brett Simchowitz
    • Center for Patient SafetyDana-Farber Cancer Institute
  • Tejal K. Gandhi
    • Harvard Medical School
    • Division of General Internal MedicineBrigham and Women’s Hospital
  • Larissa Nekhlyudov
    • Harvard Medical School
    • Department of Ambulatory Care and PreventionHarvard Medical School
    • Harvard Vanguard Medical Associates
  • David M. Studdert
    • Melbourne Law SchoolUniversity of Melbourne
  • Ann Louise Puopolo
    • Risk Management Foundation of the Harvard Medical Institutions
  • Lawrence N. Shulman
    • Center for Patient SafetyDana-Farber Cancer Institute
    • Harvard Medical School
Original Article

DOI: 10.1007/s11606-009-0982-0

Cite this article as:
Weingart, S.N., Saadeh, M.G., Simchowitz, B. et al. J GEN INTERN MED (2009) 24: 702. doi:10.1007/s11606-009-0982-0



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

Copyright information

© Society of General Internal Medicine 2009