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October 2008 Issue

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Reporting Test Results Ranks as a Common Medical Error

By Katie Pence
Published October 2008

You’ve heard it since grade school: Everyone makes mistakes.

Even your doctor’s office, according to a study that shows testing errors within primary care practices occur most commonly during implementation and in the reporting process.

These findings were published in a recent edition of Quality and Safety in Health Care.

Nancy Elder,MD, associate professor of family medicine and coinvestigator of the study, says that she and colleagues examined the entire continuum of testing and analyzed almost 1,000 errors in eight family medicine practices nationally.

Medical tests include blood tests, X-rays, Pap smears and other,more procedural tests. Errors can occur throughout the testing process: The wrong test can be ordered or administered; the results can get lost or misinterpreted by the doctor; or the patientmay not be given results.

“All serious mistakes and errors related to testing were reported over a secure Internet site,” says Elder.

“One week out of every four, we had an intensive reporting period where we had everyone in the office—staff, doctors, clerks and so forth—list all testing mistakes, even minor ones.”

Elder says about a quarter of the errors were related to reporting test results to the doctor—they were incomplete, late or lost.

She says the next two leading causes were errors in test implementation—the wrong test was done or the specimen was lost—and administrative errors, usually related to mistakes in filing the results or putting them into the patient’s medical record.

“All together, these kinds of problems accounted formore than 60 percent of the errors,” she says.

“That is a whole lot of mistakes.”

She says that although most mistakes only resulted in lost time or inconvenience for patients, 18 percent of the errors led to physical or emotional harm.

“We found that these adverse consequences occurred mostly among people, ages 45 to 64, who were also African-American or Hispanic,” she says, adding that the harm usually occurred during the implementation process.

Elder says in light of these results, further studies are being conducted to assess risks within practices that have many black and Latino patients.

“I currently have another grant to study the testing process and find ways to make the whole process safer,” she says.

“We don’t know why minority patients are affected more adversely by the testing process. There isn’t one answer to this problem. This is a complex process that takes place over many days and in many different locations.

“We can’t just tweak one thing and make it better.”

In the meantime, Elder urges patients to get involved in the process. “Doctors need to educate their patients about the test being administered, and patients need to be sure to keep current addresses and contact information in their file,” she says.

She stresses that the patient should not consider no news to be good news.

“If you don’t hear back from the office about the results, give thema call to follow up,” she says. “Make sure that the right tests were done and that you know the results and what theymean for you and your health.”

The study was funded by the American Academy of Family Physicians and the U.S. Agency for Healthcare Research and Quality.

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