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Publication Briefs

Study Suggests Significant Proportion of New Abdominal Aortic Aneurysms are not Recorded in VA’s Electronic Medical Record


  • Of the 91 Veterans with abdominal aortic aneurysms newly identified by CT, 60% lacked documentation in their VA electronic medical record (EMR) within three months of CT detection, and 18% were never documented during an average follow-up of more than three years.
  • Radiologists infrequently notified the clinical teams of aortic abnormalities, and notification did not appear more common for larger as opposed to smaller abnormalities. The average size of missed abnormalities in this study cohort was 3.4 cm, and 9% were 5.5 cm or larger.
  • More than 40% of Veterans with new aortic aneurysms identified on CT scan had no follow-up contact with the provider who ordered the test, suggesting a potential mechanism for missed results.
  • There was no evidence that any of the aneurysms ruptured or that deaths resulted from the delayed follow-up.

There is growing concern that missed test results constitute an important threat to patient safety. This study examined the frequency with which newly identified abdominal aortic aneurysms were accompanied by evidence of clinician recognition of the abnormality in VA’s electronic medical record. Investigators obtained radiology reports for 91 Veterans who underwent CT scans of the abdomen and pelvis during 2003 in two Midwestern VAMCs. Medical records also were reviewed, including data on demographics, comorbid conditions, and risk factors for aneurysms. Information from the EMR also was collected concerning the duration of time that elapsed from the initial CT scan until evidence that the aortic aneurysm was recognized by a clinician appeared in the patient’s EMR. Current clinical guidelines recommend that patients with aneurysms >3 cm undergo annual follow-up imaging, while aneurysms >5.5 cm should be considered for surgical repair.


  • These results are based on data from 2003 that were collected at two rural VAMCs.
  • The retrospective chart review did not allow for the assessment of aspects of care that were not documented in the EMR, which may have resulted in an underestimation of communication between VA radiology and clinical services.


  • VA has been on the leading edge of patient safety for many years, and recently funded a patient safety center at the Houston VA specifically charged with improving test results management.

Drs. Wahls, Cram and Rosenthal are part of HSR&D’s Center for Research in the Implementation of Innovative Strategies in Practice, Iowa City.

PubMed Logo Gordon JR, Wahls T, Carlos RC, Pipinos II, Rosenthal GE, Cram P. Failure to Recognize Newly Identified Aortic Dilations in a Healthcare System with an Advanced Electronic Medical Record. Ann Intern Med 2009 July 7;151(1):21-27.

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HSR requires notification by HSR-funded investigators about all articles accepted for publication. These journal articles are reviewed by HSR and publication briefs or summaries are written for a select number of articles that are then forwarded to VHA Central Office leadership to keep them informed about important findings or information. Articles to be summarized are selected by HSR based on timeliness of the findings, interest of leadership, or potential impact on the organization. Publication briefs are written for only a small number of HSR published articles. Visit the HSR citations database for a complete listing of HSR articles and presentations.

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