Referrals from primary care practitioners to specialists are fraught with uncertainty. As many as half1 of the approximately 100 million referrals ordered each year in the U.S.2 are not completed: patients opt out, scheduling gets jumbled, critical information is either not sent or not received; communication breaks down, and the systems we all rely on are incompletely designed to keep track of what did or did not transpire.

In addition to the fiscal and operational impacts of inadequately processed referrals are the risks to patients not being seen for serious medical concerns—or being seen, but with incomplete follow up. According to CRICO’s national Comparative Benchmarking System (CBS), 23% of outpatient cases filed from 2012–2016 with a missed or delayed diagnosis (N=2,521) had a breakdown in referral management. Nearly three-quarters (73%) of those patients suffered a high-severity injury or died. While such cases are often resolved without an insurance indemnity payment, all malpractice cases exact an emotional and appreciable toll on everyone involved. They also serve to expose underlying risks for all patients for whom a clinically significant specialty referral is ordered. pie chart with two slices: 89% and 11%

To address a concern of this scale and potential for patient harm, CRICO and the Institute for Healthcare Improvement/National Patient Safety Foundation joined forces earlier this year to convene a panel of experts (including EHR vendors) and produce a comprehensive outline of practical steps organizations can take to reduce the risk of referrals-related medical errors. That document, Closing the Loop: A Guide to Safer Ambulatory Referrals in the EHR Era, identifies nine potential patient safety gaps in the referrals process along with the expert panels’ specific recommendations for closing those gaps.

Each recommendation in the paper (released 11.29.17) is supported with strategies and tools for implementation. Acknowledging that all stakeholders—organizational leaders, EHR vendors, clinicians, support staff, and patients and families—play roles in building and maintaining a closed-loop referral process, the panel identified the primary stakeholder(s) accountable for each suggested tool or strategy. Of courses, bridging the gaps in the referral process will only be possible with the concerted, coordinated efforts of all stakeholders.


  1. Weiner M, Perkins AJ, Callahan CM. 2010. Errors in completion of referrals among older urban adults in ambulatory care. Journal of Evaluation in Clinical Practice. 6(1):76–81.
  2. Barnett ML, Song Z, Landon BE. 2012. Trends in physician referrals in the United States, 1999–2009. Archives of Internal Medicine. 172(2):163–170.

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