Several systemic factors may hinder communication of test results to patients and clinicians. This article describes a research project in Australia, "Delivering safe and effective test result communication, management and follow-up." Along with previously identified test result communication challenges such as workflow and technology, this paper highlights the need for national thresholds for critical laboratory results.

Missed or failure to follow up on test results threatens patient safety. This qualitative study used volunteers to explore consumer perspectives related to test result management. Participants identified several challenges that patients experience with test-results management, including systems-level factors related to the emergency department and patient-level factors impacting understanding of test results.

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.  

This review examined whether use of health information technology could improve physician awareness of actionable test results and follow-up of test results. The included studies were of variable quality, and though some did demonstrate improvement in test result management using health information technology, there was no consistent effect. The authors conclude that health information technology alone is not sufficient to close safety gaps in test result management.

This systematic review of falls among individuals with speech, language, and voice disability found that these populations are often excluded from studies of falls. However, there is some evidence that communication disability leads to increased risk of falls and the authors call for further study for this population.

Inadequate test result follow-up places patients at risk of delayed diagnosis, especially in the ambulatory setting. Diverse stakeholders in Australia established an agenda for enhancing test result management, which included better governance, improved use of technology, and consistent patient engagement. A WebM&M commentary explored two incidents where poor test result follow-up led to patient harm.

While prior research has shown that computerized provider order entry and clinical decision support systems have the potential to improve patient safety, less is known about the impact of such systems in intensive care units. In this systematic review and meta-analysis, investigators found an 85% decrease in prescribing errors and a 12% reduction in ICU mortality rates in critical care units that converted from paper orders to commercially available computerized provider order entry systems.

Prior research demonstrates that interruptions in health care can compromise patient safety. In this study, researchers observed interruptions experienced by nuclear medicine technologists in their work environment and found that some interruptions were helpful. In addition, technologists had developed personal strategies to optimize for safety.

This qualitative study of medication prescribing practices at long-term care facilities uncovered multiple safety hazards, including inadequate handoffs, insufficient information flow, and lack of a robust safety culture. The results suggest that both systems approaches and team training are needed to improve medication safety in long-term care facilities.

Patients with communication disabilities, such as impaired hearing or speech, are at risk for adverse events while hospitalized, as discussed in a prior WebM&M commentary. This literature review found a need for further studies of patient safety and communication disabilities with more specific information about the nature, timing, contributing factors, and consequences of adverse events. Prospective and standardized data collection is required to address this high-risk population.

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Providing test results directly to patients is one way in which enhanced patient engagement could improve safety, as failure to appropriately follow up on test results is a recognized cause of diagnostic errors. Accomplishing this will require endorsement from physicians, and this survey examines the attitudes of Australian emergency physicians regarding direct provision of test results to patients. The majority of physicians expressed discomfort with patients having direct access to test results, mainly because physicians feared patients would experience undue anxiety or lack the knowledge necessary to interpret the results. More physicians supported providing patients with direct access to normal test results than abnormal test results, mirroring the findings of a prior survey of primary care providers. Physicians were more supportive of direct release of test results if it would decrease their own workload. The results of this survey reveal the need for careful exploration of the best methods to increase patient engagement without disregarding clinicians' concerns. A previous AHRQ WebM&M interview with Dave deBronkart discussed allowing patients to access their medical records.

This study sought to validate 25 factors that critical care nurses perceived to be associated with subsequent deterioration following intrahospital transfer from intensive care units (ICUs) to ward inpatient units. Patient complexity was most commonly linked to post-ICU adverse events, while specific system factors were associated with a lower proportion of post-ICU adverse events. These results suggest that multiple system-level interventions would be needed to improve the safety of ICU-to-ward transfers.

This review describes how researchers identified and analyzed systematic reviews on interventions to augment safe medication use. The authors provide an overview of safety improvement strategies, such as reminders and financial incentives. Medication self-management programs generally enhanced medication safety and health outcomes, but more research is needed for clinically complex populations and technology-enabled strategies.

Although use of computerized provider order entry (CPOE) is increasingly widespread, implementation in the busy environment of the emergency department (ED) is still relatively new. This systematic review of the effectiveness of CPOE in the ED found that, consistent with other systematic reviews, it did reduce medication prescribing errors. However, few studies assessed the effect of CPOE on clinician workflow, and there was no clear impact on patient safety. The unique patient safety issues in the ED are discussed in an AHRQ WebM&M perspective.

This commentary discusses how Reason's accident causation model is used to analyze adverse events and identify factors that contribute to error.

This study reports on the development of a process map for the nursing shift handoff at a geriatric care facility in Australia.

Establishing a culture of safety is an essential component of improving safety within an organization. Analysis of programs that have successfully stimulated innovation to tackle safety issues, such as the Keystone ICU project or Kaiser Permanente, have found that a critical aspect of their success has been understanding the dynamics of how groups of professionals work together. This review explores how social network analysis—a method of examining relationships in complex systems, and how these relationships influence dissemination of knowledge and innovation—has been utilized to develop health professional networks for improving quality and safety. With the growing recognition of the role of context in determining the success of patient safety efforts, social network analysis provides an important tool for developing organizational approaches to improving safety.

Following up test results in a timely fashion is a recognized patient safety problem in primary care, and inadequate follow-up systems are a source of frustration for outpatient clinicians and a relatively common source of malpractice claims. This systematic review found evidence that failure to act on abnormal radiology or laboratory results is common and clearly linked to missed or delayed diagnoses. The review also found wide variation in processes for handling test results across studies. Electronic health records (EHRs) did appear to improve test follow-up rates, although a substantial proportion of abnormal results were not followed up even with EHRs. The authors advocate for more standardized processes for informing patients of abnormal results, and recent guidelines have been published for organizational policies to improve test result communication.

Adverse events after hospital discharge are a growing driver for safety interventions, including a focus on readmissions, adverse drug events, and hospital-acquired infections. Another safety area ripe for intervention is managing test results after hospital discharge. This systematic review analyzed 12 studies and found wide variation in rates of test follow-up and related management systems. Critical test results and results for patients moving across health care settings were highlighted as particularly concerning areas that could be addressed with better clinical information systems. A past AHRQ WebM&M commentary discussed a case where a patient was incorrectly treated based on failure to follow up a urine culture after hospital discharge.