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Search results for "Diagnostic Errors"
- Journal Article
- Department of Veterans Affairs (VA)
- Diagnostic Errors
- Missed or Critical Lab Results
Journal Article > Study
Root cause analysis reports help identify common factors in delayed diagnosis and treatment of outpatients.
Davis Giardina T, King BJ, Ignaczak AP, et al. Health Aff (Millwood). 2013;32:1368-1375.
Failure to properly follow up on test results can result in missed or delayed diagnoses. This study from the Veterans Affairs (VA) system reveals the clinical impact of inadequate care processes for patients with urgent follow-up needs. By analyzing 111 root cause analyses of diagnostic error cases in the outpatient setting, the authors determined that poorly coordinated care—arising from a lack of systems to track patients needing urgent evaluation, insufficient follow-up of abnormal test results, and inadequate communication between clinicians—contributed to most of the missed or delayed diagnoses. Although electronic medical records (EMRs) should facilitate responding to abnormal test results, prior VA studies have shown that a small but clinically significant proportion of abnormal laboratory tests and radiology studies are not acted upon in a timely fashion (despite the VA having a fully integrated EMR for more than a decade). The authors advocate for refining EMR systems to better facilitate communication between clinicians and for emphasizing teamwork training in the outpatient setting.
Journal Article > Study
Notification of abnormal lab test results in an electronic medical record: do any safety concerns remain?
Singh H, Thomas EJ, Sittig DF, et al. Am J Med. 2010;123:238-244.
Unreliable test result management systems are a common problem in ambulatory care, and failure (or inability) to promptly follow up abnormal test results may lead to diagnostic errors and other safety problems. Automated alerts within electronic health records should minimize such problems. However, this study conducted in Veterans Affairs clinics found that 1 in 10 alerts for abnormal laboratory test results went unread by providers, and a large proportion of those patients did not receive timely clinical follow-up. The investigators found similar results when analyzing follow-up of alerts for abnormal imaging results. "Alert fatigue" is one possible explanation for these findings.
Journal Article > Commentary
Diagnostic errors and abnormal diagnostic tests lost to follow-up: a source of needless waste and delay to treatment.
Wahls T. J Ambul Care Manage. 2007;30:338-343.
This article frames diagnostic errors and missed test results within the context of the Crossing the Quality Chasm report and discusses potential strategies for improvement.