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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Because 25% of all outpatient medical errors can be attributed to the test-results follow up process, AMC PSO studied test result management.


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Publications such as whitepapers and guidelines derived from the AMC PSO convenings.

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    Delayed Diagnosis

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