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. Author manuscript; available in PMC: 2010 Oct 1.
Published in final edited form as: Am J Gastroenterol. 2009 Jun 23;104(10):2543–2554. doi: 10.1038/ajg.2009.324

Table 4. Characteristics and number of missed opportunities that arose directly from provider–patient encounters.

Level of process breakdown Number of patients Number of missed opportunities Most common settings Most common clinical clues involved Most common personnel involved Most common contributory factors
Medical history deficient 50 100 Provider Office (90) Anemia (65) Primary care (58) Provider:
Inpatient (7) FOBT + (18) Physician assistant (20) Deficient recording of critical history data (101)
Emergency Room (3) Hematochezia (12) Patient:
None

Physical examination deficient 64 125 Provider office (107) Anemia (73) Primary care (67) Provider:
Inpatient (15) Worsening constipation (20) Physician assistant (24) Deficient recording of critical examination data (126)
Emergency room (3) Hematochezia (9) Patient:
Declined (8)

Diagnostic/laboratory tests (delayed/not ordered) 59 116 Provider office (90) Anemia (80) Primary care (63) Provider:
Inpatient (20) Hematochezia (12) Physician assistant (19) Apparent lack of awareness that subsequent diagnostic testing was required (115)
Emergency room (4) FOBT + (8) Apparent lack of knowledge (35)
Radiology (2) Patient:
Patient declined (3)

Consult delayed or not requested 130 389 Provider office (320) Anemia (187) Primary Care (203) Provider:
Inpatient (41) FOBT + (74) Physician Assistant (77) Apparent lack of awareness that subsequent referral was required (341)
Emergency Room (17) Previous polyps (58) Patient (23) Patient:
Hematochezia (49) Geriatrics (18) Declined (68)
Worsening constipation (40) Emergency Medicine (11) Cancelled appt (39)
Missed appt (12)