Missed hypothyroidism diagnosis uncovered by linking laboratory and pharmacy data

Although diagnostic errors are important, they have received less attention than medication errors. Timely follow-up of abnormal laboratory test results represents a critical aspect of the diagnostic process, and failures at this step are a cause of delayed or missed diagnosis, resulting in suboptimal clinical outcomes and malpractice litigation. We linked laboratory and pharmacy databases to (1) explore the potential for linking laboratory and pharmacy databases to uncover diagnostic errors, and (2) determine the frequency of failed follow-up of elevated levels of thyroid-stimulating hormone (TSH).

We downloaded TSH test results for 2 consecutive years from a laboratory database and linked this database with a pharmacy database to screen for patients with TSH levels of 20 mU/mL or higher who were not receiving levothyroxine. Patients with elevated TSH levels lacking prescriptions were followed up by telephone and record review.

During the 2-year period, 982 (2.7%) of 36 760 unique patients tested for TSH level had elevated TSH levels. Of these patients, 177 (18.0%) had no recorded levothyroxine prescriptions. We attempted to contact 177 patients with high TSH levels who were not taking thyroid medications and reached 123 (69.5%). Of the 123 patients we were able to reach, 12 in 2000 and 11 in 2001 were unaware of their abnormal test results or a diagnosis of hypothyroidism, representing 2.3% of 982 patients with elevated TSH levels. We were unable to reach another 54 patients (5.5% of the total number of patients with elevated TSH levels) by either telephone or mail.

By linking laboratory and pharmacy databases, we uncovered patients who did not undergo follow-up for abnormal TSH results. Conservatively, there was no follow-up for abnormal TSH results in more than 2% of patients, and another 5% of patients were lost to follow-up and possibly unaware of their results. Uncovering patients with missed diagnosis illustrates a potential use of linking laboratory and pharmacy databases to identify vulnerabilities in the care system and improve patient safety.