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Publication Briefs

Focus Groups Recommend Strategies to Decrease Missed Test Results

Delays in diagnosis constitute a common medical error and represent a significant threat to patient safety. Data suggest that problems with reporting test results are a frequent contributor to diagnostic delay; for example, studies have documented that 2%-18% of clinically significant abnormal clinical pathology results and 23% to 28% of clinically significant abnormal images lacked evidence of clinician awareness. Factors contributing to missed results can include organizational, provider, and patient-related factors. This paper reports on the efforts of two focus groups that formed as part of the Diagnostic Error in Medicine — A National Conference, which was held by the American Medical Informatics Association in 2008. Clinicians who were part of the focus groups were asked to develop interventions that might decrease the risk of diagnostic delay due to missed test results in the future.

The focus groups concluded that while the electronic medical record helps to improve access to test results, eliminating all missed test results would be difficult to achieve. This is due, in part, to the complex nature of the testing process that involves multiple steps and individuals across multiple disciplines. However, the focus groups did recommend several strategies that might decrease the rates of missed test results, including: improving standardization of the steps involved in the flow of test result information, greater involvement of patients to insure the follow-up of test results, and systems re-engineering to improve the management and presentation of data. They also suggest that healthcare organizations focus initial quality improvement efforts on specific tests that have been identified as high-risk for adverse impact on patient outcomes, such as tests associated with a possible malignancy or acute coronary syndrome.

PubMed Logo Wahls T and Cram P. Proposed interventions to decrease the frequency of missed test results. Advances in Health Sciences Education: Theory and Practice September 2009;14 Suppl 1:51-56.

Dr. Wahls is part of HSR&D's Center for Research in the Implementation of Innovative Strategies in Practice in Iowa City, IA.

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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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