Concern over patient safety issues associated with inadequate tracking of test results has grown over the last decade, as it can lead to delays in the recognition of abnormal test results and the absence of a tracking system to ensure short-term patient follow-up.^1,2 Missed abnormal tests and the lack of necessary clinical follow-up can lead to a late diagnosis.

During an elective diagnostic cardiac catheterization, the cardiologist unintentionally perforated the patient’s left ventricular wall with the catheter. The cardiologist failed to recognize the perforation, failed to take corrective measures to address the problem, and continued with the cardiac catheterization, including coronary angiographic imaging. Soon after the end of the procedure, the patient complained of severe chest pain and echocardiographic images revealed bleeding around the heart caused by the catheter-related ventricular wall perforation.

This piece focuses on human factors engineering including application of the SEIPS model to implement care transitions rooted in patient safety and the processes of care.