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We often hear about failures of colonoscopy to detect colorectal cancer (CRC), but failures to diagnose CRC also occur when opportunities to refer patients for diagnostic evaluations are missed or ignored. To determine the frequency and characteristics of such missed opportunities, investigators conducted a retrospective cohort study involving 551 consecutive patients with newly diagnosed CRC at a tertiary healthcare system. Two reviewers examined electronic records to identify patient-care events and determine whether clinical clues were present to warrant earlier diagnostic work-ups.
The reviewers agreed that ≥1 opportunity for CRC diagnosis had been missed in 161 (31.4%) of 513 evaluable patients (mean number of missed opportunities per p…