Missed/Delayed Actionable Labs

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The World Alliance for Patient Safety identified poor test follow-up as one of the major processes contributing to unsafe patient care.1 Failure to follow up on test results increases the risk of missed or delayed diagnoses.2-5 This problem extends to the pediatric population as well. Actionable pediatric laboratory values (diagnostic tests) are potentially delayed up to 26% of the time in preliminary investigations compared to 7-65% in adults, leading to harm and malpractice claims.6-8 For this reason, it is important that providers focus on addressing poor test follow-up in their practices. 

Measuring Your Progress

To screen, recognize and diagnose missed or delayed actionable laboratory results:  

  • Consider the following inclusion criteria for data collection:

    Inclusion Criteria – Patients with results for any of these 5 frequent, subcritical, and actionable abnormal pediatric laboratory values with potential for patient harm.

    These 5 specific, sub-acute laboratory results were selected as the focus of this project because each test is frequently ordered in primary care pediatric practices, unrecognized or untreated results can lead to harm, and unlike critical laboratory results they do not have existing safety systems in place. See Quality Measures.

    • Sexually Transmitted Infections

    • Microcystic Anemia

    • Elevated Lead

    • Postitive Strep Culture

    • TSH Abnormality

  • Consider the Project RedDE! Conceptual Model for Missed/Delayed Actionable Labs:

    • SCREEN: Do providers read and acknowledge all lab results in EHR inbox within 72 hours?

    • RECOGNIZE: Did provider document "abnormal labs" or appropriate diagnosis?

    • DIAGNOSE: Did provider take an appropriate action and document it without delay?
      Project RedDE! defined "delay" as:

      • 30 days for microcytic anemia, and elevated lead

      • 7 days for Sexually Transmitted Infections, Strep throat, andabnormal TSH"

               For more details on the above measures, please see the  measures grid.

Tools to support Reducing Diagnostic Errors in Delayed/Missed Labs

Top Tools:

At the end of the project, we surveyed participants on the tools they found to be most useful. The following is a list ranked in order of what was most helpful throughout the course of the collaborative.

  1. Creation of an algorithm or protocol – The creation of evidence-based best practice algorithm or protocol for achieving timely lab results.  Please see an example of a lead monitoring protocol from All About Children Pediatric Partners.

  2. Creation of a policy – When creating a policy addressing missed/delayed actionable labs in your practice/organization, consider the following:

    1. Who will check laboratory results when a provider goes on vacation?

    2. Who will check laboratory results over holiday weekends?

    3. What systems can be in place to ensure no laboratory results are ever missed?
      For example, in Project RedDE! many practices had all laboratory results sent to a central person ("lab doc of the day" or nurse manager) who would screen all results for anything that required urgent action

  3. Creation of a log of sent, received and viewed labsClick here to view a sample excel log that can be used to track lab orders.

  4. List of sources for abnormal values – A list of references that justify these abnormal laboratory values. Useful to help clinicians get invested into working to reduce these laboratory errors. 

  5. Dot Phrases for Documenting Action on Abnormal Laboratory Results – These phrases ensure that providers document all the important actions they need to complete to ensure these five labs are managed appropriately.

Missed/Delayed Actionable Labs Video Testimonials

Watch the below videos of some of the practices that participated in project RedDE! discussing challenges with missed or delayed actionable labs and how they addressed and overcame those challenges.

    1. World Alliance for Patient Safety. Summary of the Evidence on Patient Safety: Implications for Research. Geneva: World Health Organization, 2008.

    2. Bates DW, Leape LL. Doing better with critical test results. Jt Comm J Qual Patient Saf. 2005 February;31(2):66–67.

    3. Gandhi TK. Fumbled handoffs: one dropped ball after another. Ann Intern Med. 2005 March 1;142(5):352–358.

    4. Schiff GD. Introduction: Communicating critical test results. Jt Comm J Qual Patient Saf. 2005 February;31(2):63–65

    5. Wahls T. Diagnostic errors and abnormal diagnostic tests lost to follow-up: a source of needless waste and delay to treatment. J Ambul Care Manage. 2007 October;30(4):338–343

    6. Ealovega MW, Tabaei BP, Brandle M, Burke R, Herman WH. Opportunistic screening for diabetes in routine clinical practice. Diabetes care 2004;27:9-12.

    7. Singh H, Thomas EJ, Sittig DF, et al. Notification of abnormal lab test results in an electronic medical record: do any safety concerns remain? The American journal of medicine 2010;123:238-44.

    8. Gandhi TK, Kachalia A, Thomas EJ, et al. Missed and delayed diagnoses in the ambulatory setting: a study of closed malpractice claims. Annals of internal medicine 2006;145:488-96.

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