Despite significant medical advancement in the 21st century, diagnostic errors remain the third leading cause of death in the United States1. Abnormal, subcritical results are frequently overlooked and can lead to detrimental delays in care2. The Joint Commission lists several commonly missed diagnoses impacted by lab testing including: acute renal failure, decompensated heart failure, primary/metastatic cancer, metabolic disorders, pneumonia, and symptomatic anemia2. Particularly vulnerable situations include transitions of care where information loss is more likely following a patient handover3. In most clinical settings there are no safety nets in place with the when lab results are lost, with the culpability left dangling from the ordering provider. As laboratorians we share a pivotal role in ensuring actionable results are both presented and recognized by our clinical colleagues.
Processes for delivering critical results are well choreographed, however, a workflow for non-emergent, clinically abnormal tests is needed. Not only detrimental to the patient, ignored lab results represent a significant liability to the physician and their organization. Importantly, one-third of all malpractice cases resulting in death or disability stem from an inaccurate or delayed diagnosis4. However, with ever increasing testing needs, providers are more overwhelmed with data than ever before. Assigned responsibility rests with the ordering provider, although follow-up may prove challenging as patients step down in care or transfer their medical record. Handovers at transitions of care present a significant opportunity to lose relevant findings such as pre-cancerous lesions and steadily increasing creatinine or tumor markers. For this reason, the Joint Commission lists among its goals: “Improve communication such as getting test results to the correct person quickly”2. Failure to initiate timely therapy among these patients is detrimental to their morbidity and mortality.
Utilizing large repositories of data, several healthcare organizations are pioneering safety net protocols to catch abnormal lab and imaging findings. In California, Kaiser Permanente created the KP SureNet, composed of 54 active surveillance alerts. Examples include a follow-up flag for patients with elevated PSAs not evaluated within 12 weeks and an elevated creatinine program to identify undiagnosed chronic kidney disease5. A similar program exists at Brigham and Women’s Hospital, where follow-up lists are created for concerning colonoscopy biopsies and lung nodules found on imaging to avoid missed cancer diagnoses5. Furthermore, several Veterans Administration hospitals have adopted a pulmonary nodule tracking registry which dramatically decreased follow-up failure from 74% to 10%6.
While erring is human, it is unconscionable to miss an actionable result which could eventually harm a patient. It is more important than ever to challenge our EMR vendors and IT professionals to help us filter this signal from the noise. Advanced clinical decision support tools are needed to recognize missed lab results and route them to an appropriate provider for follow-up. Orphaned lab results should be tracked in an automated registry inside the EMR with an appropriate management plan in place for when discovered. We have a responsibility to actively help catch these results and only through building an electronic safety net will we achieve this. This is not an insurmountable task, but does require concerted teamwork among laboratorians, clinicians, and IT professionals to close the loop.
- Singh, Hardeep, et al. “The Frequency of Diagnostic Errors in Outpatient Care: Estimations from Three Large Observational Studies Involving US Adult Populations.” BMJ Quality & Safety, vol. 23, no. 9, 2014, pp. 727–731., doi:10.1136/bmjqs-2013-002627.
- Rodziewicz, Thomas L. “Medical Error Reduction and Prevention.” StatPearls [Internet]., U.S. National Library of Medicine, 4 Jan. 2021, www.ncbi.nlm.nih.gov/books/NBK499956/.
- Zimolzak, Andrew J., et al. “Why Test Results Are Still Getting ‘Lost’ to Follow-up: a Qualitative Study of Implementation Gaps.” Journal of General Internal Medicine, 2021, doi:10.1007/s11606-021-06772-y.
- Newman-Toker, David E., et al. “Serious Misdiagnosis-Related Harms in Malpractice Claims: The ‘Big Three’ – Vascular Events, Infections, and Cancers.” De Gruyter, De Gruyter, 1 Sept. 2019, www.degruyter.com/document/doi/10.1515/dx-2019-0019/html.
- “Reducing Diagnostic Errors.” Permanente Medicine, 21 Aug. 2018, permanente.org/reducing-diagnostic-errors/.
- Shelver, Jonathan, et al. “Effect of an Automated Tracking Registry on the Rate of Tracking Failure in Incidental Pulmonary Nodules.” Journal of the American College of Radiology, vol. 14, no. 6, 2017, pp. 773–777., doi:10.1016/j.jacr.2017.02.001.