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Because 25% of all outpatient medical errors can be attributed to the test-results follow up process, AMC PSO studied test result management.
Newsletter
Results Management Report
Nov 25, 2014
Patient Safety Alert 21: Results Management (PDF)
Continuing deliberations on test results management begun in 2013, the Academic Medical Center Patient Safety Organization (AMC PSO) gathered a panel of ambulatory risk management and patient safety experts to address this persistent issue.
Results Management Risks
“Workflow, user behavior, and organizational characteristics” significantly impact electronic results management processes. Our case reviews, and a focused review of the literature, identified the following risks associated with Tests Results Management and more:
- Diagnostic test volume is steadily increasing, with some clinicians estimating reviews of over 1000 results/week, creating cognitive and general work overloads
- EHR utilization is often not optimized, especially in remote, ambulatory practices
- Conflicting vendor/provider policies for results transmittal can lead to lapses in reporting and delays in follow up care
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AMC PSO
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More AMC PSO Content
Publications such as whitepapers and guidelines derived from the AMC PSO convenings.
Programmable Medical Equipment Risks and Interventions
Newsletter
Patient Safety Alert Issue 3: The AMC PSO has identified a series of practices employed to address the factors that can contribute to risk associated with programmable medical devices.
Cybersecurity and Recovery
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Patient Safety Alert Issue 32: Cybersecurity attacks topped the ECRI list of the Top 10 Health Technology Hazards for 2022.
Wrong Site Surgery Report
Newsletter
Patient Safety Alert Issue 1: The AMC PSO has identified the a series of practices employed to address the factors that can contribute to a wrong-site surgery.
Test Result Notification
Newsletter
Patient Safety Alert Issue 15: The AMC PSO recently held a collaborative convening session of its Ambulatory Patient Safety Leaders in order to both discuss current issues and possible solutions and propagate the natural progression of CRICO's established mission of helping health care providers turn credible data into effective action.
Ambulatory Safety Nets: Protecting Providers and Promoting Safety with Systems to Reduce Delayed Cancer Diagnoses
News
Ambulatory safety nets (ASNs) are person-centered programs that provide a highly reliable backup system for following up on abnormal test results when the standard follow-up process fails. Co-authored by CRICO’s Pat Folcarelli RN, MA, PhD, and Luke Sato, MD, this article about ASNs was featured in Inside Medical liability Online.
Establishing a Regional Registry for Neonatal Encephalopathy: Impact on Identification of Gaps in Practice
News
CRICO Grants
Neonatal encephalopathy continues to be a significant risk for death and disability. To address this risk, regional guidelines were developed with the support of CRICO. A neonatal encephalopathy registry was also established. The aim of this study was to identify areas of variation in practice that could benefit from quality improvement projects.
How Does Work Environment Relate to Diagnostic Quality? A Prospective, Mixed Methods Study in Primary Care
News
CRICO Grants
The aim of this CRICO-funded study was to develop a tool assessing key elements of the diagnostic assessment process and apply it to a series of diagnostic encounters examining clinical notes and encounters' recorded transcripts.
Utilization of Electronic Health Record Sex and Gender Demographic Fields: A Metadata and Mixed Methods Analysis
News
CRICO Grants
This CRICO co-funded retroactive study published in the Journal of the American Medical Informatics Association analyzed the records of patients 18 years of age or older in the Mass General Brigham health system with a first Legal Sex entry (registration requirement) between 2018 and 2022. The study was important because "Sex and gender demographic data are widely viewed as essential to providing culturally responsive gender affirming care and facilitating research and public health interventions."