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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.
Informed Refusal Patient Care
Newsletter
Patient Safety Alert Issue 30: The AMC PSO convened to discuss ways to clearly communicate the risks of refusal of an in-person visit to my patient and maintain a therapeutic alliance.
Test Result Notification
Newsletter
Patient Safety Alert Issue 15: The AMC PSO recently held a collaborative convening session of its Ambulatory Patient Safety Leaders in order to both discuss current issues and possible solutions and propagate the natural progression of CRICO's established mission of helping health care providers turn credible data into effective action.
Pharmacy Compounding Safe Practice Recommendations
Newsletter
Patient Safety Alert Issue 14: The AMC PSO recently held its follow up Medication Safety Task Force collaborative convening session to discuss the best practices regarding the issues within compounding sterile preparations and patient safety that were brought up in the first meeting.
Delayed Diagnosis
Newsletter
Patient Safety Alert Issue 11: The AMC PSO has performed an in-depth analysis of patient safety issues in the ED setting and has identified practices employed to reduce risks that were the result of missed or delayed diagnoses.
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.
Developing a Framework and Electronic Tool for Communicating Diagnostic Uncertainty in Primary Care: A Qualitative Study
News
CRICO Grants
This CRICO-funded study asked, “What are clinician and patient perspectives and innovative ways to communicate diagnostic uncertainty to patients?”