Laboratory test ordering and results management systems: a qualitative study of safety risks identified by administrators in general practice.

Paul Bowie; Lyn Halley; John McKay

Study

Laboratory test ordering and results management systems: a qualitative study of safety risks identified by administrators in general practice.

March 12, 2014

Bowie P, Halley L, McKay J. BMJ Open. 2014;4(2):e004245.

View more articles from the same authors.

In this qualitative study, outpatient practice administrators identified weaknesses in management of patient test results: system flaws, poor communication within health care teams, challenges to informing patients of results, and difficulties associated with ensuring follow-up and confidentiality. This study underscores persisting concerns related to test results management, despite longstanding work in this area.

PubMed citation

Available at

Free full text

Related Resources From the Same Author(s)

Qualitative evaluation of the Safety and Improvement in Primary Care (SIPC) pilot collaborative in Scotland: perceptions and experiences of participating care teams.

March 16, 2016

A review of significant events analysed in general practice: implications for the quality and safety of patient care.

October 14, 2009

Do we know what foundation year doctors think about patient safety incident reporting? Development of a web based tool to assess attitude and knowledge.

August 17, 2011

System hazards in managing laboratory test requests and results in primary care: medical protection database analysis and conceptual model.

January 20, 2016

Implementation of the trigger review method in Scottish general practices: patient safety outcomes and potential for quality improvement.

April 12, 2017

Patient safety skills in primary care: a national survey of GP educators.

February 4, 2015

Levels of agreement on the grading, analysis and reporting of significant events by general practitioners: a cross-sectional study.

October 29, 2008

A qualitative study of why general practitioners may participate in significant event analysis and educational peer assessment.

June 29, 2005

Twelve tips for embedding human factors and ergonomics principles in healthcare education.

December 13, 2017

A review of the current evidence base for significant event analysis.

August 27, 2008

Training health care professionals in root cause analysis: a cross-sectional study of post-training experiences, benefits and attitudes.

April 10, 2013

Measuring perceptions of safety climate in primary care: a cross-sectional study.

February 29, 2012

Understanding patient safety performance and educational needs using the 'Safety-II' approach for complex systems.

December 14, 2016

Understanding and responding when things go wrong: key principles for primary care educators.

September 28, 2016

The role of informal dimensions of safety in high-volume organisational routines: an ethnographic study of test results handling in UK general practice.

June 14, 2017

Incidence of wrong-site surgery list errors for a 2-year period in a single national health service board.

April 1, 2020

To what extent are patients involved in researching safety in acute mental healthcare?

April 6, 2022

To catch a killer: electronic sepsis alert tools reaching a fever pitch?

August 28, 2019

Systematic review and meta-analysis of the effectiveness of pharmacist-led medication reconciliation in the community after hospital discharge.

March 28, 2018

Repeat prescribing of medications: a system-centred risk management model for primary care organisations.

November 8, 2017

Implementing and evaluating patient-focused safety technology on adult acute mental health wards.

March 13, 2024

Simulation based adverse event reporting system: development and feasibility.

July 30, 2014

Participation in a system-thinking simulation experience changes adverse event reporting.

July 8, 2020

Attitudes and practices related to clinical alarms: a follow-up survey.

April 18, 2018

Patient safety in dentistry: development of a candidate 'never event' list for primary care.

August 2, 2017

Alarm burden and the nursing care environment: a 213-hospital cross-sectional study.

November 15, 2023

Never events in UK general practice: A survey of the views of general practitioners on their frequency and acceptability as a safety improvement approach

December 11, 2019

The preliminary development and testing of a global trigger tool to detect error and patient harm in primary-care records.

May 20, 2009

Effects of nursing rounds on patients' call light use, satisfaction, and safety.

September 20, 2006

More holes than cheese. What prevents the delivery of effective, high quality, and safe healthcare in England?

November 16, 2016

Methods for studying medication safety following electronic health record implementation in acute care: a scoping review.

January 10, 2024

System issues leading to "found-on-floor" incidents: a multi-incident analysis.

January 27, 2021

Review of medication error sources associated with inpatient subcutaneous insulin: recommendations for safe and cost-effective dispensing practices.

August 24, 2022

What we can do about maternal mortality—and how to do it quickly.

November 14, 2018

Twitter as a tool to enhance student engagement during an interprofessional patient safety course.

May 21, 2014

Safety in the home healthcare sector: development of a new household safety checklist.

May 9, 2012

Teaching and medical errors: primary care preceptors' views.

October 12, 2005

Empowering patients in the hospital as a new approach to reducing the burden of health care–associated infections: the attitudes of hospital health care workers.

January 6, 2016

Quality and safety indicators in anesthesia: a systematic review.

May 27, 2009

Factors influencing preceptors' responses to medical errors: a factorial survey.

October 19, 2005

The development and psychometric evaluation of a safety climate measure for primary care.

January 19, 2011

Frequency and nature of potentially harmful preventable problems in primary care from the patient's perspective with clinician review: a population-level survey in Great Britain.

September 26, 2018

Deriving a framework for a systems approach to agitated patient care in the emergency department.

May 16, 2018

Eliminating preventable death at Ascension Health.

March 14, 2007

How patients perceive a doctor's caring attitude.

September 24, 2008

Integrating incident reporting into an electronic patient record system.

March 14, 2007

Addressing dual patient and staff safety through a team-based standardized patient simulation for agitation management in the emergency department.

June 13, 2018

Patient safety during sedation by anesthesia professionals during routine upper endoscopy and colonoscopy: an analysis of 1.38 million procedures.

April 20, 2016

Contextual information influences diagnosis accuracy and decision making in simulated emergency medicine emergencies.

June 12, 2013

Observer-based tools for non-technical skills assessment in simulated and real clinical environments in healthcare: a systematic review.

June 12, 2019

Validity of unplanned admission to an intensive care unit as a measure of patient safety in surgical patients.

December 14, 2005

Observing sources of system resilience using in situ alarm simulations.

October 25, 2023

Beyond communication: the role of standardized protocols in a changing health care environment.

January 11, 2012

The weekend effect in hospitalized patients: a meta-analysis.

October 11, 2017

Hospital-wide code rates and mortality before and after implementation of a rapid response team.

December 10, 2008

A prospective controlled trial of the effect of a multi-faceted intervention on early recognition and intervention in deteriorating hospital patients.

May 12, 2010

Assessment of patients' ability to review electronic health record information to identify potential errors: cross-sectional web-based survey.

March 10, 2021

Developing expert medical teams: toward an evidence-based approach.

October 15, 2008

Evaluating clinical decision support systems: monitoring CPOE order check override rates in the Department of Veterans Affairs' computerized patient record system.

September 17, 2008

A human factors curriculum for surgical clerkship students.

January 5, 2011

Using a potentially aggressive/violent patient huddle to improve health care safety.

January 30, 2019

Effectiveness of acute care remote triage systems: a systematic review.

February 5, 2020

A comprehensive quality assurance program for personnel and procedures in radiation oncology: value of voluntary error reporting and checklists.

August 7, 2013

Information chaos in primary care: implications for physician performance and patient safety.

November 30, 2011

Partial codes—when "less" may not be "more."

June 22, 2016

Problems and paradoxes of reliability and resilience in organizational networks.

September 20, 2023

Hiding in plain sight: inconvenient facts for patient safety in non-24/7 theatre on-site staffed obstetric units.

September 6, 2023

Reliability, uncertainty and the management of error: new perspectives in the COVID-19 era.

March 9, 2022

From good intentions to successful implementation: the case of patient safety in Canada.

February 28, 2007

Impact of a pharmacist-facilitated hospital discharge program: a quasi-experimental study.

December 2, 2009

Mistake-proofing healthcare: why stopping processes may be a good start.

March 3, 2010

Critical diagnoses (critical values) in anatomic pathology.

August 9, 2006

Nurse–patient ratios as a patient safety strategy: a systematic review.

March 20, 2013

Patient safety: some progress and many challenges.

November 7, 2012

The importance of failing forward. All of us will fail and make mistakes, but how can they benefit us and our organizations?

June 27, 2012

Voluntary review of quality of care peer review for patient safety.

May 23, 2007

Patient safety in women's health care: a framework for progress.

April 18, 2007

Leadership strategies of medical school deans to promote quality and safety.

February 7, 2007

An interview with Lucian Leape.

November 2, 2005

A hospitalization from hell: a patient's perspective on quality.

March 6, 2005

The quality of pharmacologic care for vulnerable older patients.

March 6, 2005

Diagnostic errors in paediatric cardiac intensive care.

February 21, 2018

Machine learning models outperform manual result review for the identification of wrong blood in tube errors in complete blood count results.

June 29, 2022

Clinical deterioration as a nurse sensitive indicator in the out-of-hospital context: a scoping review.

January 24, 2024

The thinking doctor: clinical decision making in contemporary medicine.

August 31, 2016

'Trust but verify'—five approaches to ensure safe medical apps.

October 28, 2015

Association between opioid prescribing patterns and abuse in ophthalmology.

November 29, 2017

Nonoperating room anaesthesia: safety, monitoring, cognitive aids and severe acute respiratory syndrome coronavirus 2.

August 12, 2020

Managing clinical failure: a complex adaptive system perspective.

May 30, 2007

What context features might be important determinants of the effectiveness of patient safety practice interventions?

June 29, 2011

The role of theory in research to develop and evaluate the implementation of patient safety practices.

January 30, 2005

Disorganized care: the findings of an iterative, in-depth analysis of surgical morbidity and mortality.

November 21, 2012

Physicians and electronic health records: a statewide survey.

March 21, 2007

Comparison of quality of care for patients in the Veterans Health Administration and patients in a national sample.

March 6, 2005

How does context affect interventions to improve patient safety? An assessment of evidence from studies of five patient safety practices and proposals for research.

May 4, 2011

Microsystems in health care: Part 2. Creating a rich information environment.

March 6, 2005

The normalization of deviance in healthcare delivery.

March 3, 2010

Suicide attempts after emergency room visits: the effect of patient safety goals.

December 16, 2015

Does a unit shift report "blackout" period improve patient safety?

April 10, 2019

Alcohol and drug testing of health professionals following preventable adverse events: a bad idea.

November 19, 2014

Related Resources

Implementing a safer and more reliable system to monitor test results at a teaching university-affiliated facility in a family medicine group: a quality improvement process report.

November 1, 2023

Patient Safety Innovations

Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses of Cancer

July 31, 2023

Developing electronic clinical quality measures to assess the cancer diagnostic process.

June 21, 2023

Annual Perspective

Improving Diagnostic Safety and Quality

April 26, 2023

Annual Perspective

Patient Safety in the Ambulatory Care Setting

August 5, 2022

'I guess I'll wait to hear'- communication of blood test results in primary care a qualitative study.

August 3, 2022

Medical Office Survey on Patient Safety Culture.

September 1, 2021

Communicating findings of delayed diagnostic evaluation to primary care providers.

July 27, 2016

Measuring patient safety in primary care: the development and validation of the "Patient Reported Experiences and Outcomes of Safety in Primary Care" (PREOS-PC).

June 1, 2016

Laboratory medicine handoff gaps experienced by primary care practices: a report from the Shared Networks of Collaborative Ambulatory Practices and Partners (SNOCAP).

December 3, 2014

Measuring experiences and outcomes of patient safety in primary care: a systematic review of available instruments.

October 29, 2014

Test result communication in primary care: clinical and office staff perspectives.

August 20, 2014

Hospital-based transfusion error tracking from 2005 to 2010: identifying the key errors threatening patient transfusion safety.

March 26, 2014

"Chance favors only the prepared mind": preparing minds to systematically reduce hazards in the testing process in primary care.

March 5, 2014

From physician intent to the pharmacy label: prevalence and description of discrepancies from a cross-sectional evaluation of electronic prescriptions.

February 26, 2014

Findings and Lessons From the AHRQ Ambulatory Safety and Quality Program.

December 18, 2013

First annual review of data submitted to the ISMP National Vaccine Errors Reporting Program (VERP).

December 11, 2013

Patient Safety Toolkits.

October 30, 2013

Safety in home care: a mapping review of the international literature.

October 23, 2013

Root cause analysis reports help identify common factors in delayed diagnosis and treatment of outpatients.

August 21, 2013

A typology of electronic health record workarounds in small-to-medium size primary care practices.

August 21, 2013

Syndromic surveillance for health information system failures: a feasibility study.

August 14, 2013

Impact of individual and team features of patient safety climate: a survey in family practices.

August 14, 2013

What patients think doctors know: beliefs about provider knowledge as barriers to safe medication use.

August 14, 2013

Office-based physicians are responding to incentives and assistance by adopting and using electronic health records.

July 24, 2013

Resilient actions in the diagnostic process and system performance.

July 17, 2013

Information technology interventions to improve medication safety in primary care: a systematic review.

July 10, 2013

Advanced practice nursing students' identification of patient safety issues in ambulatory care.

April 10, 2013

Reasons for not reporting patient safety incidents in general practice: a qualitative study.

January 30, 2013

Certain uncertainties: modes of patient safety in healthcare.

December 19, 2012

See More About The Topic

Ambulatory Care

Health Care Providers

Quality and Safety Professionals

Safety Scientists

Family Medicine

Laboratory test ordering and results management systems: a qualitative study of safety risks identified by administrators in general practice.

Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses of Cancer

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Laboratory test ordering and results management systems: a qualitative study of safety risks identified by administrators in general practice.

Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses of Cancer

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site