Variation in electronic test results management and its implications for patient safety: a multisite investigation.

Judith Thomas; Maria R. Dahm; Julie Li; Peter C. Smith; Jacqui Irvine; Johanna I. Westbrook; Andrew Georgiou

Study

Variation in electronic test results management and its implications for patient safety: a multisite investigation.

August 19, 2020

Thomas J, Dahm MR, Li J, et al. J Am Med Inform Assoc. 2020;27(8):1214–1224.

View more articles from the same authors.

This qualitative study explored how clinicians ensure optimal management of diagnostic test results, a major patient safety concern. Thematic analyses identified strategies clinicians use to enhance test result management including paper-based manual processes, cognitive reminders, and adaptive use of electronic medical record functionality.

PubMed citation

Free full text

Related Resources From the Same Author(s)

Can patients contribute to enhancing the safety and effectiveness of test-result follow-up? Qualitative outcomes from a health consumer workshop.

June 2, 2021

The delivery of safe and effective test result communication, management and follow-up.

September 27, 2023

How effective are electronic medication systems in reducing medication error rates and associated harm among hospital inpatients? A systematic review and meta-analysis.

December 2, 2020

The impact of health information technology on the management and follow-up of test results—a systematic review.

May 8, 2019

Discontinuation of outpatient medications: implications for electronic messaging to pharmacies using CancelRx.

December 7, 2022

Enabling a learning healthcare system with automated computer protocols that produce replicable and personalized clinician actions.

August 4, 2021

Patient groups, clinicians and healthcare professionals agree—all test results need to be seen, understood and followed up.

December 19, 2018

The tradeoffs between safety and alert fatigue: data from a national evaluation of hospital medication-related clinical decision support.

July 29, 2020

Electronic health record-based prediction models for in-hospital adverse drug event diagnosis or prognosis: a systematic review.

March 29, 2023

Patient safety and quality improvement: ethical principles for a regulatory approach to bias in healthcare machine learning.

July 22, 2020

Improving patient safety and efficiency of medication reconciliation through the development and adoption of a computer-assisted tool with automated electronic integration of population-based community drug data: the RightRx project.

January 10, 2018

Short- and long-term effects of an electronic medication management system on paediatric prescribing errors.

January 18, 2023

Clinical data sharing improves quality measurement and patient safety.

March 24, 2021

A machine learning-based clinical decision support system to identify prescriptions with a high risk of medication error.

October 21, 2020

Partnering with patients and families living with chronic conditions to coproduce diagnostic safety through OurDX: a previsit online engagement tool.

February 15, 2023

Associations of physicians’ prescribing experience, work hours, and workload with prescription errors.

November 18, 2020

Risk factors associated with medication ordering errors.

December 16, 2020

Prevalence and causes of diagnostic errors in hospitalized patients under investigation for COVID-19.

April 12, 2023

CancelRx: a health IT tool to reduce medication discrepancies in the outpatient setting.

September 1, 2021

Safety risks and workflow implications associated with nursing-related free-text communication orders.

March 15, 2023

Associations between double-checking and medication administration errors: a direct observational study of paediatric inpatients.

August 26, 2020

Validation of an electronic trigger to measure missed diagnosis of stroke in emergency departments.

August 25, 2021

Indication alerts to improve problem list documentation.

January 26, 2022

Association between limiting the number of open records in a tele-critical care setting and retract-reorder errors.

July 21, 2021

An objective framework for evaluating unrecognized bias in medical AI models predicting COVID-19 outcomes.

June 1, 2022

Renal medication-related clinical decision support (CDS) alerts and overrides in the inpatient setting following implementation of a commercial electronic health record: implications for designing more effective alerts.

February 17, 2021

Examining medication ordering errors using AHRQ Network of Patient Safety Databases.

February 22, 2023

Alert burden in pediatric hospitals: a cross-sectional analysis of six academic pediatric health systems using novel metrics.

November 3, 2021

Impact of digitally acquired peer diagnostic input on diagnostic confidence in outpatient cases: a pragmatic randomized trial.

December 2, 2020

Safe use of the EHR by medical scribes: a qualitative study.

November 18, 2020

Maybe they had a bad day: how LGBTQ and BIPOC patients react to bias in healthcare and struggle to speak out.

September 14, 2022

The potential for leveraging machine learning to filter medication alerts.

May 4, 2022

Recommendations for the safe, effective use of adaptive CDS in the US healthcare system: an AMIA position paper.

April 21, 2021

Inviting patients to identify diagnostic concerns through structured evaluation of their online visit notes.

April 13, 2022

It's like sending a message in a bottle: a qualitative study of the consequences of one-way communication technologies in hospitals.

October 13, 2021

Nurse workarounds in the electronic health record: an integrative review.

August 12, 2020

Preliminary study of patient safety and quality use cases for ICD-11 MMS.

September 15, 2021

Seroprevalence of SARS-CoV-2 among frontline health care personnel in a multistate hospital network--13 academic medical centers, April-June 2020.

September 23, 2020

Are operating room distractions, interruptions, and disruptions associated with performance and patient safety? A systematic review and meta-analysis.

May 19, 2021

Can decision support combat incompleteness and bias in routine primary care data?

April 7, 2021

Communication through the electronic health record: frequency and implications of free text orders.

July 29, 2020

Bias at warp speed: how AI may contribute to the disparities gap in the time of COVID-19.

September 9, 2020

Why test results are still getting "lost" to follow-up: a qualitative study of implementation gaps.

May 12, 2021

Expanding frontiers of risk management: care safety in nursing home during COVID-19 pandemic.

September 30, 2020

Learning from patient safety incidents involving acutely sick adults in hospital assessment units in England and Wales: a mixed methods analysis for quality improvement.

August 25, 2021

The MedSafer study-electronic decision support for deprescribing in hospitalized older adults: a cluster randomized clinical trial.

February 2, 2022

Nursing home staff turnover and perceived patient safety culture: results from a national survey.

November 4, 2020

The safety implications of missed test results for hospitalised patients: a systematic review.

February 23, 2011

Failure to follow-up test results for ambulatory patients: a systematic review.

January 11, 2012

'More than words' - interpersonal communication, cognitive bias and diagnostic errors.

August 11, 2021

"Are we there yet?" Ten persistent hazards and inefficiencies with the use of medication administration technology from the perspective of practicing nurses.

March 22, 2023

High-priority drug-drug interaction clinical decision support overrides in a newly implemented commercial computerized provider order-entry system: override appropriateness and adverse drug events.

May 20, 2020

Using automated methods to detect safety problems with health information technology: a scoping review.

February 8, 2023

Applying requisite imagination to safeguard electronic health record transitions.

May 18, 2022

Trust and medical AI: the challenges we face and the expertise needed to overcome them.

April 21, 2021

Impact of smart pump-electronic health record interoperability on patient safety and finances at a community hospital

August 25, 2021

Is there a link between nursing home reported quality and COVID-19 cases? Evidence from California skilled nursing facilities.

August 12, 2020

Finding the right balance: an evidence-informed guidance document to support the re-opening of Canadian nursing homes to family caregivers and visitors during the coronavirus disease 2019 pandemic.

October 28, 2020

Changes in unprofessional behaviour, teamwork, and co-operation among hospital staff during the COVID-19 pandemic.

September 28, 2022

Safety climate associated with adverse events in nursing homes: a national VA study.

August 26, 2020

Implementation of the I-PASS handoff program in diverse clinical environments: a multicenter prospective effectiveness implementation study.

November 16, 2022

Application of human factors methods to understand missed follow-up of abnormal test results.

November 11, 2020

Managing teamwork in the face of pandemic: evidence-based tips.

June 24, 2020

Clinical and financial implications of second-opinion surgical pathology review.

April 7, 2021

Patient factors and hospital outcomes associated with atypical presentation in hospitalized older adults with COVID-19 during the first surge of the pandemic.

August 18, 2021

Association of diagnostic stewardship for blood cultures in critically ill children with culture rates, antibiotic use, and patient outcomes: results of the Bright STAR Collaborative.

May 18, 2022

Variation in the reporting of elective surgeries and its influence on patient safety indicators.

July 6, 2022

Omissions of care in nursing homes: a uniform definition for research and quality improvement.

November 18, 2020

Organizational characteristics and perceptions of clinical event notification services in healthcare settings: a study of health information exchange.

December 23, 2020

Effectiveness of a 'Do not interrupt' bundled intervention to reduce interruptions during medication administration: a cluster randomised controlled feasibility study.

March 15, 2017

Community discharge among post-acute nursing home residents: an association with patient safety culture?

June 30, 2021

Improving allergy documentation: a retrospective electronic health record system-wide patient safety initiative.

January 1, 2022

The impact of electronic health record interoperability on safety and quality of care in high-income countries: systematic review.

October 5, 2022

Addressing systemic racism in nursing homes: a time for action.

April 14, 2021

Closing the loop on test results to reduce communication failures: a rapid review of evidence, practice and patient perspectives.

November 25, 2020

Emergency physicians' views of direct notification of laboratory and radiology results to patients using the internet: a multisite survey.

March 25, 2015

Impact of commercial computerized provider order entry (CPOE) and clinical decision support systems (CDSSs) on medication errors, length of stay, and mortality in intensive care units: a systematic review and meta-analysis.

April 26, 2017

Interdisciplinary Quality Improvement Conference: using a revised morbidity and mortality format to focus on systems-based patient safety issues in a VA hospital: design and outcomes.

November 12, 2014

COVID-19: patient safety and quality improvement skills to deploy during the surge.

June 24, 2020

Influences of physical layout and space on patient safety and communication in ambulatory oncology practices: a multisite, mixed method investigation.

July 14, 2021

Cancer diagnostic delay in Northern and Central Italy during the 2020 lockdown due to the coronavirus disease 2019 pandemic.

October 21, 2020

Implementation and sustainability of a medication reconciliation toolkit: a mixed methods evaluation.

August 5, 2020

Electronic medical record-based interventions to encourage opioid prescribing best practices in the emergency department.

September 30, 2020

Signs and symptoms to determine if a patient presenting in primary care or hospital outpatient settings has COVID-19 disease.

July 29, 2020

Personality traits and traumatic outcome symptoms in registered nurses in the aftermath of a patient safety incident.

July 22, 2020

National and institutional trends in adverse events over time: a systematic review and meta-analysis of longitudinal retrospective patient record review studies.

March 3, 2021

The evolving curriculum in quality improvement and patient safety in undergraduate and graduate medical education: a scoping review.

February 15, 2023

Modifications to medical emergency team activation criteria and implications for patient safety: a point prevalence study.

March 24, 2021

Comparison of a voluntary safety reporting system to a global trigger tool for identifying adverse events in an oncology population.

August 3, 2022

Patient engagement in the inpatient setting: a systematic review.

December 18, 2013

Association between implementing comprehensive learning collaborative strategies in a statewide collaborative and changes in hospital safety culture.

September 2, 2020

Health professional networks as a vector for improving healthcare quality and safety: a systematic review.

January 11, 2012

The effect of computerized provider order entry systems on clinical care and work processes in emergency departments: a systematic review of the quantitative literature.

May 22, 2013

Drug-drug interactions and actual harm to hospitalized patients: a multicentre study examining the prevalence pre- and post-electronic medication system implementation.

April 10, 2024

Patient errors in use of injectable antidiabetic medications: a need for improved clinic-based education.

November 4, 2020

A program to provide clinicians with feedback on their diagnostic performance in a learning health system.

October 28, 2020

Home health staff perspectives on infection prevention and control: implications for Coronavirus Disease 2019.

December 23, 2020

Improving the specificity of drug-drug interaction alerts: can it be done?

April 6, 2022

Patient safety culture in assisted living: staff perceptions and association with state regulations.

November 30, 2022

Hospital ward adaptation during the COVID-19 pandemic: a national survey of academic medical centers.

September 23, 2020

Related Resources

Perspective

Cybersecurity and How to Maintain Patient Safety

March 27, 2024

Interview

In Conversation with...Barbara Pelletreau and John Riggi about Cybersecurity

March 27, 2024

Clinical pathway adherence and missed diagnostic opportunities among children with musculoskeletal infections.

September 6, 2023

Patient Safety Innovations

Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses of Cancer

July 31, 2023

WebM&M Cases

Bandemia as a Harbinger of Stercoral Colitis and Impending Perforation.

July 31, 2023

Patient Safety Innovations

Remote Response Team and Customized Alert Settings Help Improve Management of Sepsis

May 31, 2023

Interorganizational health information exchange-related patient safety incidents: a descriptive register-based qualitative study.

May 24, 2023

Delays in care during the COVID-19 pandemic in the Veterans Health Administration.

May 3, 2023

Reducing diagnostic errors in the emergency department at the time of patient treatment.

March 29, 2023

Patient Safety Innovations

Journal Article

Study

Catching those who fall through the cracks: integrating a follow-up process for emergency department patients with incidental radiologic findings.

November 16, 2022

Barcode medication administration software technology use in the emergency department and medication error rates.

August 31, 2022

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

June 29, 2022

Usability of a human factors-based clinical decision support in the emergency department: lessons learned for design and implementation.

May 11, 2022

When no news is bad news: improving diagnostic testing communication through patient engagement.

March 9, 2022

Technology-based closed-loop tracking for improving communication and follow-up of pathology results.

February 2, 2022

Assessing the impact of virtual medication history technicians on medication reconciliation discrepancies.

December 1, 2021

Bringing the clinical laboratory into the strategy to advance diagnostic excellence.

September 22, 2021

Validation of an electronic trigger to measure missed diagnosis of stroke in emergency departments.

August 25, 2021

Emergency physician perceptions of electronic health record usability and safety.

May 12, 2021

Patient Safety Innovations

Algorithm-Based Decision Support System Guides Trauma Staff During Initial Treatment, Leading to Fewer Medical Errors

March 3, 2021

Health Information Technology for Engaging Patients in Diagnostic Decision Making in Emergency Departments.

February 17, 2021

Association of display of patient photographs in the electronic health record with wrong-patient order entry errors.

December 2, 2020

A program to provide clinicians with feedback on their diagnostic performance in a learning health system.

October 28, 2020

Streamlining care in crisis: rapid creation and implementation of a digital support tool for COVID-19.

October 21, 2020

A doctor gave me an inept diagnosis for a neurological problem. I should know: I’m a neurologist.

October 14, 2020

Prevalence and characterisation of diagnostic error among 7-day all-cause hospital medicine readmissions: a retrospective cohort study.

September 16, 2020

Emergency department monitor alarms rarely change clinical management: an observational study.

September 16, 2020

Varying rates of patient identity verification when using computerized provider order entry.

May 27, 2020

Interview

In Conversation With... David Gruen, MD

January 31, 2020

Perspective

Artificial Intelligence and Diagnostic Errors

January 31, 2020

See More About The Topic

Emergency Departments

Information Professionals

Emergency Medicine

Diagnostic Errors

Diagnostic Test Interpretation Error

Variation in electronic test results management and its implications for patient safety: a multisite investigation.

Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses of Cancer

Remote Response Team and Customized Alert Settings Help Improve Management of Sepsis

Catching those who fall through the cracks: integrating a follow-up process for emergency department patients with incidental radiologic findings.

Algorithm-Based Decision Support System Guides Trauma Staff During Initial Treatment, Leading to Fewer Medical Errors

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Variation in electronic test results management and its implications for patient safety: a multisite investigation.

Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses of Cancer

Remote Response Team and Customized Alert Settings Help Improve Management of Sepsis

Catching those who fall through the cracks: integrating a follow-up process for emergency department patients with incidental radiologic findings.

Algorithm-Based Decision Support System Guides Trauma Staff During Initial Treatment, Leading to Fewer Medical Errors

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