The frequency of missed test results and associated treatment delays in a highly computerized health system

BMC Family Practice

Volumn 8, Issue , 2007, Pages

  Wahls, Terry L ^a,b   Cram, Peter M ^b  

^a VETERANS AFFAIRS MEDICAL CENTER   (United States)

^b UNIVERSITY OF IOWA   (United States)

Author keywords

[No Author keywords available]

Indexed keywords

ARTICLE; DIAGNOSTIC ERROR; ENDOCRINE DISEASE; HEALTH CARE MANAGEMENT; HEALTH CARE PERSONNEL; HEALTH CARE SYSTEM; HEALTH PROGRAM; HEALTH SURVEY; HEART DISEASE; HUMAN; IMAGING; INFORMATION PROCESSING; LABORATORY TEST; MEDICAL INFORMATION; OUTPATIENT DEPARTMENT; THERAPY DELAY; EPIDEMIOLOGY; GOVERNMENT; HEALTH CARE DELIVERY; MEDICAL RECORD; PRIMARY HEALTH CARE; REMINDER SYSTEM; STATISTICS; TIME; UNITED STATES;

DELIVERY OF HEALTH CARE; DIAGNOSTIC ERRORS; HEALTH CARE SURVEYS; HUMANS; MEDICAL RECORDS SYSTEMS, COMPUTERIZED; PRIMARY HEALTH CARE; REMINDER SYSTEMS; TIME FACTORS; UNITED STATES; UNITED STATES DEPARTMENT OF VETERANS AFFAIRS;

EID: 34250348778     PISSN: None     EISSN: 14712296     Source Type: Journal    
DOI: 10.1186/1471-2296-8-32     Document Type: Article

References (29)

1. Missed and Delayed Diagnoses in the Emergency Department: A Study of Closed Malpractice Claims From 4 Liability Insurers. A Kachalia TK Gandhi AL Puopolo C Yoon EJ Thomas R Griffey TA Brennan DM Studdert, Ann Emerg Med 2006 16997424
2. Analysis of diagnostic error in paid malpractice claims with substandard care in a large healthcare system. TV Holohan J Colestro J Grippi J Converse M Hughes, South Med J 2005 98 1083 1087 10.1097/01.smj.0000170729.51651.f7 16351028
3. Malpractice claims: finding the silver lining. EJ Thomas, South Med J 2005 98 1065 10.1097/01.smj.0000194520.60422.20 16351024
4. Preventing medical injury. LL Leape AG Lawthers TA Brennan WG Johnson, QRB Qual Rev Bull 1993 19 144 149 8332330
5. The nature of adverse events in hospitalized patients. Results of the Harvard Medical Practice Study II. LL Leape TA Brennan N Laird AG Lawthers AR Localio BA Barnes L Hebert JP Newhouse PC Weiler H Hiatt, N Engl J Med 1991 324 377 384 1824793
6. Understanding diagnostic errors in medicine: a lesson from aviation. H Singh LA Petersen EJ Thomas, Qual Saf Health Care 2006 15 159 164 10.1136/qshc.2005.016444 16751463
7. Diagnostic error in internal medicine. ML Graber N Franklin R Gordon, Arch Intern Med 2005 165 1493 1499 10.1001/archinte.165.13.1493 16009864
8. Diagnostic errors in medicine: a case of neglect. M Graber, Jt Comm J Qual Patient Saf 2005 31 106 113 15791770
9. Failure to recognize and act on abnormal test results: the case of screening bone densitometry. P Cram GE Rosenthal R Ohsfeldt RB Wallace J Schlechte GD Schiff, Jt Comm J Qual Patient Saf 2005 31 90 97 15791768
10. Outpatient diagnostic errors: unrecognized hyperglycemia. D Edelman, Eff Clin Pract 2002 5 11 16 11874191
11. Communication factors in the follow-up of abnormal mammograms. EG Poon JS Haas PA Louise TK Gandhi E Burdick DW Bates TA Brennan, J Gen Intern Med 2004 19 316 323 15061740 10.1111/j.1525-1497.2004.30357.x
12. Prescribing potassium despite hyperkalemia: medication errors uncovered by linking laboratory and pharmacy information systems. GD Schiff HC Aggarwal S Kumar RA McNutt, Am J Med 2000 109 494 497 10.1016/S0002-9343(00)00546-5 11042241
13. Missed hypothyroidism diagnosis uncovered by linking laboratory and pharmacy data. GD Schiff S Kim N Krosnjar MF Wisniewski J Bult L Fogelfeld RA McNutt, Arch Intern Med 2005 165 574 577 10.1001/archinte.165.5.574 15767535
14. Patient safety concerns arising from test results that return after hospital discharge. CL Roy EG Poon AS Karson Z Ladak-Merchant RE Johnson SM Maviglia TK Gandhi, Ann Intern Med 2005 143 121 128 16027454
15. Missing clinical information during primary care visits. PC Smith R raya-Guerra C Bublitz B Parnes LM Dickinson VR Van JM Westfall WD Pace, JAMA 2005 293 565 571 10.1001/jama.293.5.565 15687311
16. Diagnostic Result Reporting Challenges in the Veterans Health Administration. T Wahls H T C P, Joint Commission Journal on Quality and Safety 2007
17. Issues and initiatives in the testing process in primary care physician offices. JM Hickner DH Fernald DM Harris EG Poon NC Elder JW Mold, Jt Comm J Qual Patient Saf 2005 31 81 89 15791767
18. Design and implementation of a comprehensive outpatient Results Manager. EG Poon SJ Wang TK Gandhi DW Bates GJ Kuperman, J Biomed Inform 2003 36 80 91 10.1016/S1532-0464(03)00061-3 14552849
19. Overriding of drug safety alerts in computerized physician order entry. SH van der J Aarts A Vulto M Berg, J Am Med Inform Assoc 2006 13 138 147 10.1197/jamia.M1809 16357358
20. Human probability matching behaviour in response to alarms of varying reliability. JP Bliss RD Gilson JE Deaton, Ergonomics 1995 38 2300 2312 7498189
21. Behavioural implications of alarm mistrust as a function of task workload. JP Bliss MC Dunn, Ergonomics 2000 43 1283 1300 10.1080/001401300421743 11014752
22. From aviation to medicine: applying concepts of aviation safety to risk management in ambulatory care. R Wilf-Miron I Lewenhoff Z Benyamini A Aviram, Qual Saf Health Care 2003 12 35 39 10.1136/qhc.12.1.35 12571343
23. Improving safety with information technology. DW Bates AA Gawande, N Engl J Med 2003 348 2526 2534 10.1056/NEJMsa020847 12815139
24. Inadequate follow-up of abnormal mammograms. BD McCarthy MU Yood EA Boohaker RE Ward M Rebner CC Johnson, Am J Prev Med 1996 12 282 288 8874693
25. Risk of Delayed Treatment Due To Missed Results. T Wahls T Haugen P Cram, J Gen Interl Med 2006 21 s4 1 283 10.1111/j.1525-1497.2006.00469.x
26. "I wish I had seen this test result earlier!": Dissatisfaction with test result management systems in primary care. EG Poon TK Gandhi TD Sequist HJ Murff AS Karson DW Bates, Arch Intern Med 2004 164 2223 2228 10.1001/archinte.164.20.2223 15534158
27. Comparison of methods for detecting medication errors in 36 hospitals and skilled-nursing facilities. EA Flynn KN Barker GA Pepper DW Bates RL Mikeal, Am J Health Syst Pharm 2002 59 436 446 11887410
28. Adverse drug event reporting. Improving the low US reporting rates. SA Edlavitch, Arch Intern Med 1988 148 1499 1503 10.1001/archinte.148.7.1499 3382293
29. Patient notification and follow-up of abnormal test results. A physician survey. EA Boohaker RE Ward JE Uman BD McCarthy, Arch Intern Med 1996 156 327 331 10.1001/archinte.156.3.327 8572844