The frequency of missed test results and associated treatment delays in a highly computerized health system
The authors sought to address a gap in the available data by assessing the frequency of missed test results (diagnostic studies) and their impact on patients in delayed diagnosis and/or treatment by surveying clinic practitioners in the VA's Midwest Healthcare Network. Wahls and Cram review the literature and note the mounting evidence that missed results constitute a common medical error and represent a significant threat to patient safety. 
The investigators sent an anonymous online survey to primary care practitioners to determine the number, type, and impact of missed test results within the a two week period. The survey response was 54% (of 198 survey requests sent) and was performed as part of ongoing quality improvement activities within the VA.
The online survey consisted of 6 parts; (1) information on average patient load and the number of days spent in clinic; (2) a selection list of the type of results missed in the preceding two week period, any resulting treatment or diagnostic delays, and several follow-up questions; (3) the frequency of patient requests for results ordered in a different clinic or by a different provider (i.e., from "diverted" patients); (4) processes and procedures clinicians used to avoid missing test results in their own practices; (5) how practitioners ensured patient follow-up of abnormal test results; (6) and lastly, respondents were asked to rate eight potential interventions for "helpfulness" in avoiding missed results. 
The researchers supported the findings of their earlier survey that found as many as 50% of responding clinicians had experienced missed test results and over third reported treatment delays as a result. The current survey found that of the missed results reported, 29% were imaging studies, 22% common clinical pathology tests, 9% anatomic pathology reports, and 40% other studies. Treatment delays resulting from missed tests for one or more patients encountered was reported by 30% of the respondents.
The survey also asked about existing and proposed methods for avoiding missed results (including the use of electronic notification, paper-based logs, and local procedures for the communication of abnormal results) and the impact of patients scheduling visits explicitly seeking test results that had not been communicated to them from an earlier visit.
The authors make a strong case that mishandling of abnormal or critical test results has a real impact on patients by delaying treatment and diagnosis especially with respect to cancer cases. From an informatics standpoint, they describe how the VA EMR system (VistA) can be set by the clinician to automatically alert them when results are returned, but have a choice of seeing all results, or only flagging abnormal, or critical studies. When asked in the survey about the relative helpfulness of different interventions, electronic notification was ranked third behind improved procedures and processes.
In their conclusion, Walhs and Cram underscore the importance of reviewing the processes around reporting and follow-up for abnormal test results and studies when health systems convert from paper processes to an EMR, stating that they may experience an increase in missed results if process controls which existed in the paper based system to ensure review of abnormal results are not replicated in some fashion in the EMR based system.
The frequency of missed test results and associated treatment delays in a highly computerized health system Wahls T, Cram, P, BMC Family Practice 2007; 8:32
- The frequency of missed test results and associated treatment delays in a highly computerized health system. http://www.biomedcentral.com/1471-2296/8/32