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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
Our Patient Safety Organization convenes clinical leaders to identify and mitigate emerging risks.
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More AMC PSO Content
Publications such as whitepapers and guidelines derived from the AMC PSO convenings.
No Surgical Items Left Behind
Newsletter
While the occurrence is rare, Massachusetts reported rising rates of retained surgical items over the past several years.
Hospital at Home (HaH)
Newsletter
Patient Safety Alert Issue 36: When implementing or expanding a HaH program, consider programmatic resources, goals, and the patient population to identify and mitigate risks and deliver safe, high-quality care.
Medication Administration in the Ambulatory Setting
Newsletter
Patient Safety Alert Issue 26: The AMC PSO convened a panel of nursing leaders to review risks in the medication delivery processes in the ambulatory setting and discuss potential interventions aimed at mitigating the risks associated with medication administration.
Patient & Visitor De-escalation
Newsletter
Patient Safety Alert Issue 25: The AMC PSO convened a panel of safety leaders to review recent trends and discuss novel interventions to mitigate the risk for hospital workplace violence, especially from patients and visitors.
Medication Errors and Malpractice: What a Decade of Cases Reveals About Risk Across the Care Continuum
News
Published in MPLA’s Inside Medical Liability, the article uses a decade of Candello med mal data to highlight medication error risks and the need for coordinated safeguards across every stage of care.
Ambulatory Safety Nets: Protecting Providers and Promoting Safety with Systems to Reduce Delayed Cancer Diagnoses
News
CRICO Grants
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.
Teleradiology Medical Malpractice Cases
News
Candello Member
This June 4, 2024, podcast by RSNA, features Dr. Francis Deng, a Diagnostic Neuroradiologist and Assistant Professor at Johns Hopkins University, who interviews CRICO’s Dr. Adam Schaffer about the characteristics of teleradiology medical malpractice cases.