Found in The Literature
Failure to Report Lab Test Results to Outpatients
Casalino LP, Dunham D, Chin MH, et al. Frequency of failure to inform patients of clinically significant outpatient test results. Arch Intern Med 2009;169:1123–1129.
Summary and Commentary by Michael Astion, MD, PhD
As laboratorians, our focus is to provide accurate and timely tests results. But once the lab reports a result, we rarely know if the patient actually sees the result. Now, a new study indicates, that at least in the outpatient setting, many patients are never notified of a abnormal test results.
In this largest study to date, researchers conducted a structured medical record review to determine the frequency at which abnormal results were not communicated to the patient. The authors reviewed random medical records on 5,434 patients being cared for by 23 primary care practices in 19 community-based and four academic medical centers located in the Midwestern and Western U. S. The study looked at 14 common tests: 13 blood tests, and one imaging test, mammography.
The medical record review revealed 1,889 results considered clinically significantly abnormal, which was defined as a result “nearly any physician would agree that the patient should be informed of the result” because of its potential immediate or long-term effect on the patient’s health. They found that in 135 (7.1%) of these 1,889 cases, the patient was not properly informed of the result. Overall, the best performing practice had a 0% failure rate, and the worst performing practice had a failure rate of 26.2%. Notification failures included cases of a HbA1c at >18% and a hematocrit of 28.6%.
Doctor speaking to patient after reviewing
the patient’s abnormal result in the doctor’s electronic inbox.
The authors also performed a literature review and identified five processes likely to be associated with lower failure rates: 1. routing of all test results to the ordering care provider; 2. having the care provider formally acknowledge all results; 3. informing patients of all results, normal or abnormal; 4. documenting that the patient was told of the test results; and 5. telling patients that no news is not good news, meaning that patients should contact the care provider if they receive no information about the test result. Using a written survey and a structured interview, the 23 practices participating in the study were assessed for the presence or absence of these five processes. In addition, the 23 practices were surveyed regarding their use of electronic medical records (EMRs).
One of the main findings from the survey and interviews was that the best performing primary care practices tended to have implemented more of the quality processes. Another softer, but interesting association was that the worst performing practices used both paper records and EMRs, as opposed to EMRs alone or paper alone. The most disturbing finding was that eight of the 23 practices (35%), specifically had a policy telling patients that “no news is good news,” meaning that if patients did not hear from the provider, the patient should assume that the result is within normal limits. This policy is considered dangerous and is in direct disagreement with the “no news is not good news” policies strongly favored by patient safety experts in professional societies, government agencies, and patient advocacy groups.
As a major improvement over previous similar studies, these new results offer some helpful bits of information on how labs might improve patient safety. For example, the methods could be adapted by laboratorians to determine the “failure-to-inform” rate at their institutions. These institutional rates could then be compared with the study’s overall rate (7.1%), as well as the more detailed results provided by the authors. Laboratorians may also want to consider implementing systems that incorporate the five processes likely to be associated with lower failure rates. Theoretically, these processes are easier to implement if an organization has a highly functional and complete EMR (see Box, below).
While not many labs have that luxury, overall, it seems clear that the processes make sense, and the evidence base to support them is growing.
EMR Functionality That Can Decrease the Incidence of “Failure to Notify” Patients of Abnormal Lab Results
- All results sent to care provider’s electronic inbox
- Flagging of abnormal results in care provider’s electronic inbox
- Requirement that care provider must electronically acknowledge viewing the results
- Automated or semi-automated creation and mailing of test reports to patients
- Allowing patients access to their electronic medical records
- Auto paging of abnormal results to wide-screen pagers of patient’s care provider or physician on-call