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PSNet: Patient Safety Network
Journal Article
Study

Notification of abnormal lab test results in an electronic medical record: do any safety concerns remain?

Singh H, Thomas EJ, Sittig DF, et al. The American journal of medicine. 2010;123:238-44.

Unreliable test result management systems are a common problem in ambulatory care, and failure (or inability) to promptly follow up abnormal test results may lead to diagnostic errors and other safety problems. Automated alerts within electronic health records should minimize such problems. However, this study conducted in Veterans Affairs clinics found that 1 in 10 alerts for abnormal laboratory test results went unread by providers, and a large proportion of those patients did not receive timely clinical follow-up. The investigators found similar results when analyzing follow-up of alerts for abnormal imaging results. "Alert fatigue" is one possible explanation for these findings.