Case Study
A primary care provider sees a patient acutely who is “not feeling well” in the morning. The exam is unremarkable and the provider orders a complete blood count (CBC) and chemistry panel. At 4:55pm, the lab calls to report a critical potassium level of 6.0. The provider has already left for the day and is not called. Due to the provider’s unpleasant demeanor and grumpiness, the staff rarely calls after hours. Later that night, the patient presents to the ED with syncope, cardiac arrhythmia, and a potassium level of 6.3.
Diagnostic test results are a critical component of patient care and the tests we order are increasing in numbers and complexity. Missed or delayed follow-up can lead to adverse outcomes, including delayed diagnoses, unnecessary complications, and potential medical liability claims. To prevent these errors, medical providers must implement strategies to ensure that diagnostic test results, whether sent directly or forwarded to the office, are received, reviewed, and acted upon promptly.
National safety organizations, including the Joint Commission, the National Patient Safety Foundation (NPSF), and the Agency for Healthcare Research and Quality (AHRQ), provide valuable published guidance to help practices avoid these pitfalls.
- Establish Clear Communication Protocols
One of the most effective ways to avoid missed results is to create standardized processes and a structured communication system for receiving and reviewing test outcomes. This should include documenting who is responsible for receiving, reviewing, and acting upon results. For example, appointing a dedicated person or team to monitor and process incoming test results ensures accountability and reduces the likelihood of results falling through the cracks. - Implement Electronic Health Record (EHR) Alerts
Leveraging technology can significantly improve the management of test results. The NPSF suggests the use of EHR alerts or notifications to flag pending results or abnormal findings. Automated alerts can trigger action by clinicians and staff, ensuring timely follow-up. For example, an EHR system can alert the ordering provider when a result is available, or when abnormal findings are reported. - Ensure Test Results Are Tied to Clinical Workflow
Diagnostic test result management must be integrated into the clinical workflow. Practices should ensure that test results are reviewed by the ordering physician, ideally within a set timeframe, and that abnormal results prompt an immediate follow-up action. This should be part of the practice’s daily routine, where results are discussed at regular team meetings or with a designated staff member who cross-checks results against patients’ charts. - Patient Notification Systems
Patient notification is critical to ensuring that diagnostic results are acted upon. Practices should have clear protocols for notifying patients of both normal and abnormal results. It is essential that patients are informed promptly, as delayed notification can lead to worsened conditions. Implementing a system for automatic patient alerts or reminders for follow-up appointments can also help ensure continuity of care. Patient portals are not a reliable means of closed loop communication of abnormal test results. - Conduct Regular Audits
Regular audits of the test result management process can help identify potential gaps and areas for improvement. The Institute for Healthcare Improvement (IHI) advocates for routine audits to track test result completion rates, timeliness of communication, and follow-up actions, allowing practices to identify and address any weaknesses in their process.
Conclusion
Avoiding missed diagnostic test results requires a combination of clear protocols, technological tools, effective communication strategies, and ongoing monitoring. By following these best practices, medical providers can significantly reduce the risk of errors, improving patient safety and care outcomes.
The information provided herein does not, and is not intended to, constitute legal, medical, or other professional advice; instead, this information is for general informational purposes only. The specifics of each state’s laws and the specifics of each circumstance may impact its accuracy and applicability, therefore, the information should not be relied upon for medical, legal, or financial decisions and you should consult an appropriate professional for specific advice that pertains to your situation.
Article originally published in 1Q25 Copiscope.
