The safety implications of missed test results for hospitalised patients: a systematic review

  • Callen J
  • Georgiou A
  • Li J
 et al. 
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BACKGROUND: Failure to follow-up test results is a critical safety issue. The objective was to systematically review evidence quantifying the extent of failure to follow-up test results and the impact on patient outcomes. METHODS: The authors searched Medline, CINAHL, Embase, Inspec and the Cochrane Database from 1990 to March 2010 for English-language articles which quantified the proportion of diagnostic tests not followed up for hospital patients. Four reviewers independently reviewed titles, abstracts and articles for inclusion. RESULTS: Twelve studies met the inclusion criteria and demonstrated a wide variation in the extent of the problem and the impact on patient outcomes. A lack of follow-up of test results for inpatients ranged from 20.04% to 61.6% and for patients treated in the emergency department ranged from 1.0% to 75% when calculated as a proportion of tests. Two areas where problems were particularly evident were: critical test results and results for patients moving across healthcare settings. Systems used to manage follow-up of test results were varied and included paper-based, electronic and hybrid paper-and-electronic systems. Evidence of the effectiveness of electronic test management systems was limited. CONCLUSIONS: Failure to follow up test results for hospital patients is a substantial problem. Evidence of the negative impacts for patients when important results are not actioned, matched with advances in the functionality of clinical information systems, presents a convincing case for the need to explore solutions. These should include interventions such as on-line endorsement of results

Author-supplied keywords

  • Australia
  • Clinical
  • Diagnostic Tests,Routine
  • Diagnostic tests
  • Emergencies
  • Follow-up
  • Health
  • Humans
  • Information Systems
  • Inpatients
  • Medical Errors
  • Medline
  • New South Wales
  • Patients
  • Quality of Health Care
  • Research
  • Research Support
  • Safety
  • Safety Management
  • Test results
  • Universities
  • Wales
  • management
  • methods
  • utilization

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  • J Callen

  • A Georgiou

  • J Li

  • J I Westbrook

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