Diagnostic Errors and Abnormal Diagnostic Tests Lost to Follow‐Up: A Source of Needless Waste and Delay to Treatment

Diagnostic errors are an important and often underappreciated source of medical error, needless delays to treatment, and needlessly wasted resources. Almost 65% of diagnostic errors have an important contribution of system errors, of which many are an abnormal test result that was lost to follow-up, that is, missed results. These system problems that contribute to missed results may represent low-hanging fruit for those who wish to reduce diagnostic errors in their institution. The rate of missed results and associated treatment delay are discussed. The system factors and human factors that contribute to these errors are discussed along with strategies that can be adopted to reduce these errors.

[1]  Alastair Baker,et al.  Crossing the Quality Chasm: A New Health System for the 21st Century , 2001, BMJ : British Medical Journal.

[2]  E. Thomas.  Malpractice claims: finding the silver lining. , 2005, Southern medical journal.

[3]  Christopher L. Roy,et al.  Patient Safety Concerns Arising from Test Results That Return after Hospital Discharge , 2005, Annals of Internal Medicine.

[4]  E. Thomas,et al.  Understanding diagnostic errors in medicine: a lesson from aviation , 2006, Quality and Safety in Health Care.

[5]  P. Cram,et al.  Patient preference for being informed of their DXA scan results. , 2004, Journal of clinical densitometry.

[6]  P. Maurette,et al.  [To err is human: building a safer health system]. , 2002, Annales francaises d'anesthesie et de reanimation.

[7]  N. Franklin,et al.  Diagnostic error in internal medicine. , 2005, Archives of internal medicine.

[8]  J. Westfall,et al.  Missing clinical information during primary care visits. , 2005, JAMA.

[9]  David Edelman,et al.  Outpatient diagnostic errors: unrecognized hyperglycemia. , 2002, Effective clinical practice : ECP.

[10]  G D Schiff,et al.  Prescribing potassium despite hyperkalemia: medication errors uncovered by linking laboratory and pharmacy information systems. , 2000, The American journal of medicine.

[11]  David W. Bates,et al.  Design and implementation of a comprehensive outpatient Results Manager , 2003, J. Biomed. Informatics.

[12]  J P Bliss,et al.  Human probability matching behaviour in response to alarms of varying reliability. , 1995, Ergonomics.

[13]  P. Cram,et al.  The frequency of missed test results and associated treatment delays in a highly computerized health system , 2007, BMC family practice.

[14]  T. Holohan,et al.  Analysis of Diagnostic Error in Paid Malpractice Claims with Substandard Care in a Large Healthcare System , 2005, Southern medical journal.

[15]  B. McCarthy,et al.  Patient notification and follow-up of abnormal test results. A physician survey. , 1996, Archives of internal medicine.

[16]  Douglas H. Fernald,et al.  Issues and initiatives in the testing process in primary care physician offices. , 2005, Joint Commission journal on quality and patient safety.

[17]  Peter Cram,et al.  The continuing problem of missed test results in an integrated health system with an advanced electronic medical record. , 2007, Joint Commission journal on quality and patient safety.

[18]  D. Bates,et al.  Improving safety with information technology. , 2003, The New England journal of medicine.

[19]  R Wilf-Miron,et al.  From aviation to medicine: applying concepts of aviation safety to risk management in ambulatory care , 2003, Quality & safety in health care.

[20]  David W Bates,et al.  "I wish I had seen this test result earlier!": Dissatisfaction with test result management systems in primary care. , 2004, Archives of internal medicine.

[21]  Robert A McNutt,et al.  Missed hypothyroidism diagnosis uncovered by linking laboratory and pharmacy data. , 2005, Archives of internal medicine.

[22]  David W. Bates,et al.  Primary care physician attitudes concerning follow-up of abnormal test results and ambulatory decision support systems , 2003, Int. J. Medical Informatics.

[23]  Robert B Wallace,et al.  Failure to recognize and act on abnormal test results: the case of screening bone densitometry. , 2005, Joint Commission journal on quality and patient safety.

[24]  Elisabeth Burdick,et al.  Communication factors in the follow-up of abnormal mammograms , 2004, Journal of General Internal Medicine.

[25]  Stephen S Raab,et al.  Effectiveness of Toyota process redesign in reducing thyroid gland fine-needle aspiration error. , 2006, American journal of clinical pathology.

[26]  Sharon Sung BS,et al.  Direct reporting of laboratory test results to patients by mail to enhance patient safety , 2008, Journal of General Internal Medicine.

[27]  Mariea C. Dunn,et al.  Behavioural implications of alarm mistrust as a function of task workload , 2000, Ergonomics.

[28]  B D McCarthy,et al.  Inadequate follow-up of abnormal mammograms. , 1996, American journal of preventive medicine.