The frequency of missed test results and associated treatment delays in a highly computerized health system.
Approach to Improving Safety
Failure to properly follow up on tests has been associated with missed diagnoses in the ambulatory setting. This survey evaluated the extent to which faulty systems limit a physician's ability to follow up after tests have been ordered. Even though the physicians worked within the highly computerized and integrated Veterans Affairs system, nearly one-third reported a clinically significant delay in establishing a diagnosis for a patient due to missed or delayed test results. In general, clinicians did not have a systematized method for following up on results (whether normal or abnormal), as has been documented in prior research, and the authors note that active systems for ensuring appropriate follow-up are needed even when an electronic medical record is present.