Where and when might errors have occurred?

A 70-year-old man in very good health experiences a syncopal episode after standing unsupported for 20 minutes. His pulse was 46 and color ashen with circumoral cyanosis.
Paramedics were called, and he was taken to the nearest emergency department. After extensive tests and 3 weeks of home monitoring, it was determined that the patient needed a pacemaker. Following the pacemaker insertion, it was determined that his cholesterol was elevated, and he was started on medication. The patient stated that he had been put on statins once before by his primary care physician and was not able to tolerate them. This time, the medication was to be closely monitored.
One month following his pacemaker insertion and the start of this medication, the patient saw his primary care physician. The physician went over his lab tests, for which samples were drawn before the visit. When the patient asked about his cholesterol, he was told that no lipid levels had been measured. When the patient further asked about the report on his pacemaker surgery, the physician replied that he had no report.