Proposed interventions to decrease the frequency of missed test results.

Numerous studies have identified that delays in diagnosis related to the mishandling of abnormal test results are an import contributor to diagnostic errors. Factors contributing to missed results included organizational factors, provider factors and patient-related factors. At the diagnosis error conference continuing medical education conference in 2008, attendees attended two focus groups dedicated to identification of strategies to lower the frequency of missed results. The recommendations were reviewed and summarized. Improved standardization of the steps involved in the flow of test result information, greater involvement of patients to insure the follow up of test results, and systems re-engineering to improve the management and presentation of data. Focusing the initial interventions on the specific tests which have been identified as high risk for adverse impact on patient outcomes such as tests associated with a possible malignancy or acute coronary syndrome will likely have the most significant impact on clinical outcome and patient satisfaction with care.