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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
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More AMC PSO Content
Publications such as whitepapers and guidelines derived from the AMC PSO convenings.
Patient ID Risks & the Intersection of Electronic Health Records
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Patient Safety Alert Issue 28: The AMC PSO recently convened a multidisciplinary group of stakeholders across its membership to review and discuss strategies for safer patient identification.
Medication Administration in the Ambulatory Setting
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Patient & Visitor De-escalation
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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.
Electronic Health Record Risks in the Emergency Department
Newsletter
Patient Safety Alert Issue 27: The AMC PSO convened a panel of Emergency Medicine thought leaders to identify significant areas of concern and to explore potential mitigation strategies for use of electronic health record risks in the Emergency Department
Ambulatory Safety Nets: Protecting Providers and Promoting Safety with Systems to Reduce Delayed Cancer Diagnoses
News
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.
How Does Work Environment Relate to Diagnostic Quality? A Prospective, Mixed Methods Study in Primary Care
News
CRICO Grants
The aim of this CRICO-funded study was to develop a tool assessing key elements of the diagnostic assessment process and apply it to a series of diagnostic encounters examining clinical notes and encounters' recorded transcripts.
Diagnostic Errors Linked to Nearly 800,000 Deaths or Cases of Permanent Disability in U.S.
News
CRICO in partnership with Johns Hopkins Armstrong Institute Center for Diagnostic Excellence, conducted a study that indicates misdiagnosis of disease or other medical conditions leads to hundreds of thousands of deaths and permanent disabilities each year in the U.S.