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Proposed interventions to decrease the frequency of missed test results

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Abstract

Numerous studies have identified that delays in diagnosis related to the mishandling of abnormal test results are an import contributor to diagnostic errors. Factors contributing to missed results included organizational factors, provider factors and patient-related factors. At the diagnosis error conference continuing medical education conference in 2008, attendees attended two focus groups dedicated to identification of strategies to lower the frequency of missed results. The recommendations were reviewed and summarized. Improved 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. Focusing the initial interventions on the specific tests which have been identified as high risk for adverse impact on patient outcomes such as tests associated with a possible malignancy or acute coronary syndrome will likely have the most significant impact on clinical outcome and patient satisfaction with care.

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References

  • Cram, P., Rosenthal, G. E., Ohsfeldt, R., Wallace, R. B., Schlechte, J., & Schiff, G. D. (2005). Failure to recognize and act on abnormal test results: The case of screening bone densitometry. Joint Commission Journal on Quality and Patient Safety Index, 31(2), 90–97.

    Google Scholar 

  • Edelman, D. (2002). Outpatient diagnostic errors: Unrecognized hyperglycemia. Effective Clinical Practice, 5(1), 11–16.

    Google Scholar 

  • Gordon, J. R., Wahls, T., Carlos, P., & Cram, P. (2009). Failure to recognize newly identified aortic dilations in a health care system with an advanced electronic medical record. Annals of Internal Medicine, 151(1), 21–27.

    Google Scholar 

  • Graber, M. L., Franklin, N., & Gordon, R. (2005). Diagnostic error in internal medicine. Archives of Internal Medicine, 165(13), 1493–1499.

    Article  Google Scholar 

  • Holohan, T. V., Colestro, J., Grippi, J., Converse, J., & Hughes, M. (2005). Analysis of diagnostic error in paid malpractice claims with substandard care in a large healthcare system. Southern Medical Journal, 98(11), 1083–1087.

    Article  Google Scholar 

  • Kachalia, A., Gandhi, T. K., Puopolo, A. L., Yoon, C., Thomas, E. J., Griffey, R., et al. (2006). Missed and delayed diagnoses in the emergency department: A study of closed malpractice claims from 4 liability insurers. Annals of Emergency Medicine.

  • Leape, L. L., Brennan, T. A., Laird, N., Lawthers, A. G., Localio, A. R., Barnes, B. A., et al. (1991). The nature of adverse events in hospitalized patients. Results of the Harvard Medical Practice Study II. New England Journal of Medicine, 324(6), 377–384.

    Article  Google Scholar 

  • Leape, L. L., Lawthers, A. G., Brennan, T. A., & Johnson, W. G. (1993). Preventing medical injury. QRB Quality Review Bulletin, 19(5), 144–149.

    Google Scholar 

  • Nepple, K. G., Joudi, F. N., Hillis, S. L., & Wahls, T. L. (2008). Prevalence of delayed clinician response to elevated prostate-specific antigen values. Mayo Clinic Proceedings, 83(4), 439–448.

    Article  Google Scholar 

  • Peleg, I., & Wahls, T. (2008). Missed opportunities for earlier diagnosis of colorectal cancer occur. Journal of General Internal Medicine, 23(s2), 89–443.

    Article  Google Scholar 

  • Poon, E. G., Gandhi, T. K., Sequist, T. D., Murff, H. J., Karson, A. S., & Bates, D. W. (2004a). “I wish I had seen this test result earlier!”: Dissatisfaction with test result management systems in primary care. Archives of Internal Medicine, 164(20), 2223–2228.

    Article  Google Scholar 

  • Poon, E. G., Haas, J. S., Louise, P. A., Gandhi, T. K., Burdick, E., Bates, D. W., et al. (2004b). Communication factors in the follow-up of abnormal mammograms. Journal of General Internal Medicine, 19(4), 316–323.

    Article  Google Scholar 

  • Schiff, G. D., Aggarwal, H. C., Kumar, S., & McNutt, R. A. (2000). Prescribing potassium despite hyperkalemia: Medication errors uncovered by linking laboratory and pharmacy information systems. American Journal of Medicine, 109(6), 494–497.

    Article  Google Scholar 

  • Schiff, G. D., Kim, S., Krosnjar, N., Wisniewski, M. F., Bult, J., Fogelfeld, L., et al. (2005). Missed hypothyroidism diagnosis uncovered by linking laboratory and pharmacy data. Archives of Internal Medicine, 165(5), 574–577.

    Article  Google Scholar 

  • Singh, H., Petersen, L. A., & Thomas, E. J. (2006). Understanding diagnostic errors in medicine: A lesson from aviation. Quality and Safety in Health Care, 15(3), 159–164.

    Article  Google Scholar 

  • Thomas, E. J. (2005). Malpractice claims: Finding the silver lining. Southern Medical Journal, 98(11), 1065.

    Article  Google Scholar 

  • Wahls, T. (2007). Diagnostic errors and abnormal diagnostic tests lost to follow-up: a source of needless waste and delay to treatment. Journal of Ambulatory Care Management. 30(4), 338–343

    Google Scholar 

  • Wahls, T. L., & Cram, P. M. (2007). The frequency of missed test results and associated treatment delays in a highly computerized health system. BMC Family Practice, 8, 32.

    Article  Google Scholar 

  • Wahls, T., Haugen, T., & Cram, P. (2007). The continuing problem of missed test results in an integrated health system with an advanced electronic medical record. Joint Commission Journal on Quality and Patient Safety Index, 33(8), 485–492.

    Google Scholar 

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Acknowledgments

This material is the result of work supported with resources and the use of facilities in the Center for Research in the Implementation of Innovative Strategies in Practice (CRIISP) at the Iowa City VA Medical Center.

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Correspondence to Terry L. Wahls.

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Financial Disclosures: The authors declare they have no competing interests.

Disclaimer: The views expressed in this article are those of the authors and do not necessarily reflect the policy or position of the Department of Veterans Affairs.

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Wahls, T.L., Cram, P. Proposed interventions to decrease the frequency of missed test results. Adv in Health Sci Educ 14 (Suppl 1), 51–56 (2009). https://doi.org/10.1007/s10459-009-9180-4

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  • DOI: https://doi.org/10.1007/s10459-009-9180-4

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