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- Error Reporting and Analysis
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- Missed or Critical Lab Results
Journal Article > Review
Callen J, Georgiou A, Li J, Westbrook JI. BMJ Qual Saf 2011;20:194-199.
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.
Washington, DC: Department of Veterans Affairs, Office of Inspector General; October 23, 2013. Report No. 13-00505-348.
Journal Article > Study
How context affects electronic health record–based test result follow-up: a mixed-methods evaluation.
Menon S, Smith MW, Sittig DF, et al. BMJ Open. 2014;4:e005985.
Failure to follow up on test results is a common source of missed or delayed diagnoses, especially in the outpatient setting. Even in systems with highly-integrated electronic health records, such as the Veterans Affairs health system, problems with test follow-up persist. This study explored various sociotechnical factors that may contribute to missed test results. Although the vast majority of facilities required that unread alerts remain in the ordering providers' inbox for at least 14 days, only about 70% of facilities had some mechanism to prevent alerts from remaining unread. Interviews with patient safety managers and information technologists revealed a number of generalizable high-risk scenarios. Tests ordered by trainees frequently led to issues with follow-up since trainees often rotated to other sites and rarely followed full protocols to ensure test follow-up. Even when a surrogate was assigned to receive alerts during a clinician's absence, there were many problems with lack of clear responsibilities and communication. A previous AHRQ WebM&M commentary discussed the many issues that contribute to missed test follow-up.
Journal Article > Commentary
Russo E, Sittig DF, Murphy DR, Singh H. Healthc (Amst). 2016;4:285-290.
Using a case study on missed and delayed follow-up of test results, this commentary explores challenges and opportunities that data from electronic health records present for patient safety research. Key barriers to utilizing electronic health record data to inform improvement work include restricted access to data, difficulty interpreting data, and workforce issues.