Reviews of closed claims and patient safety assessments reveal that inadequate clinical laboratory and diagnostic test tracking is a top factor leading to patient injury.
Test result management in ambulatory practices can pose a significant challenge for physicians and practice managers. To be fully successful, tracking test results requires a standardized workflow. It is not a process that can rely solely on due diligence. Standardizing test result management reduces the reliance on memory and helps newcomers understand and use the process safely.1
To remain effective, the process should be continuously evaluated for failure points and refined as necessary. When offices enhance associated workflow systems, it is imperative to redesign test-tracking steps to coincide with the changing technology. Avoid delays in test result management by immediately addressing unexpected internal and external events, such as unavailability of assigned staff to maintain workflow or a disrupted testing center report transmission.
Missed or delayed diagnosis leading to serious injury or death can occur if no formal tracking process is in place. In a systematic review of six test-tracking studies, four of the studies revealed a missed cancer diagnosis as a significant finding. Several study participants reported lack of established procedures of who was responsible for what, including follow-up with the patient.2
Findings from 221 patient safety assessments performed by The Doctors Company from 2014 through early 2015 revealed 70 consequential test-tracking findings. The most common finding was that practices depended on passively waiting for test results or for the patient to return before checking the result. This finding validates that continuing challenges are associated with test-tracking standardization among large multispecialty and small office practices.
The goal of every practice is to provide optimal care to patients. Although tracking methods can differ depending on many variables in the practice setting, effectively managing patient care always includes steps to ensure result reconciliation, physician review, patient notification, and a plan of care. The Agency for Healthcare Research and Quality (AHRQ) has published a toolkit that provides information and resources to help physicians’ offices, clinics, and other ambulatory care facilities assess and improve the testing process in their offices. An example of the test-tracking process is outlined below.3
A fully established process incorporates a standardized workflow that includes the following:
AHRQ and The Doctors Company support the following requirements for successful practice improvements:4
Implementing a standardized test-tracking system can create job satisfaction for those responsible for the process. Physicians can be reassured that test results are handled appropriately and that patients are more involved in their own care. Most importantly, the potential for patient harm will be reduced and liability avoided.
By Dana Faber, RN, BS, Patient Safety Risk Manager.
The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider in light of all circumstances prevailing in the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.