Tests need to be tracked from order to completion, receipt, and action. | Failures need to be visible, rather than invisibly falling through cracks. | Each step needs to be acknowledged and documented. Critical tests ordered but not performed and results lacking acknowledgment or expected action need to be tracked. |
Develop standardized approach for every test and test-generating area to define and flag clinically significant abnormal results. | “Panic values” were a major advance in the 1970s, but nonurgent, action-requiring abnormal results are now the biggest problem. Lack of standardized, coded system is difficult for clinicians and for systematic tracking. | Each testing area should delineate criteria for abnormal results using three levels of urgency—immediate/life threatening, urgent, and nonurgent but critical to follow up—defining time frames for receipt and action for each level of urgency and tagging results meeting criteria. |
Eliminate ambiguities regarding whom to contact for critical abnormal results, and delineate their responsibilities. | Confusion leads to errors, particularly related to responsibilities of ordering specialists and cross-covering physicians versus primary caregivers. Redesign is needed to overcome fragmented outpatient services and increasing inpatient “shift work.” | Emerging consensus that initial responsibility belongs to the ordering clinician to receive, act on, and/or relay critical results, backed up by the covering clinician when ordering clinician is unavailable, for more urgent results. |
Outpatients should be informed about all test results, even normal results. | Creating expectation that they will hear about all results allows patients to serve as reliability backstop for unreported results. | Multiple ways to communicate with patients depending on the result, the patient, and available technology. Web-based secure patient “portals” are increasingly useful as ways to post results. |
Tracking and system oversight monitoring | Just as someone needs to “own” each critical result, someone needs to be responsible for tracking outstanding results and identifying problems and system improvement opportunities. | Create test result quality office/person to track abnormal results unaddressed after predefined intervals, to troubleshoot/investigate when clinicians are not reachable or results are sent to wrong physician, and to monitor and improve performance based on incidents and aggregated data. |
Advanced systems to support clinicians in test results management | Further overloading busy clinicians with more tests to follow up without supporting ability to do so is not effective system redesign. Need automation, delegation, and cognitive support tools. | Results management system redesign and tools featuring interoperability with all testing areas (e.g., cardiology, endoscopy), linking to contextual information (past results, problems, drugs), and electronic decision support to identify and streamline carrying out next actions. |