title: The frequency of missed test results and associated treatment delays in a highly computerized health system.
abstract: BACKGROUND
  Diagnostic errors associated with the failure to follow up on abnormal diagnostic studies ("missed results") are a potential cause of treatment delay and a threat to patient safety. Few data exist concerning the frequency of missed results and associated treatment delays within the Veterans Health Administration (VA).
  
  
  OBJECTIVE
  The primary objective of the current study was to assess the frequency of missed results and resulting treatment delays encountered by primary care providers in VA clinics.
  
  
  METHODS
  An anonymous on-line survey of primary care providers was conducted as part of the health systems ongoing quality improvement programs. We collected information from providers concerning their clinical effort (e.g., number of clinic sessions, number of patient visits per session), number of patients with missed abnormal test results, and the number and types of treatment delays providers encountered during the two week period prior to administration of our survey.
  
  
  RESULTS
  The survey was completed by 106 out of 198 providers (54 percent response rate). Respondents saw and average of 86 patients per 2 week period. Providers encountered 64 patients with missed results during the two week period leading up to the study and 52 patients with treatment delays. The most common missed results included imaging studies (29 percent), clinical laboratory (22 percent), anatomic pathology (9 percent), and other (40 percent). The most common diagnostic delays were cancer (34 percent), endocrine problems (26 percent), cardiac problems (16 percent), and others (24 percent).
  
  
  CONCLUSIONS
  Missed results leading to clinically important treatment delays are an important and likely underappreciated source of diagnostic error.
authors.affiliation: Iowa City Department of Veterans Affairs (VA) Medical Center, Iowa City, IA, USA. Terry.Wahls@va.gov
authors.forename: Terry L
authors.initials: TL
authors.lastname: Wahls
authors.forename: Peter M
authors.initials: PM
authors.lastname: Cram
mesh_terms: D003695:Delivery of Health Care / Q000706:statistics & numerical data*; D003951:Diagnostic Errors / Q000706:statistics & numerical data*; D019538:Health Care Surveys; D006801:Humans; D016347:Medical Records Systems, Computerized / Q000706:statistics & numerical data*; D011320:Primary Health Care / Q000706:statistics & numerical data; D017010:Reminder Systems / Q000706:statistics & numerical data; D013997:Time Factors; D014481:United States; D014493:United States Department of Veterans Affairs / Q000706:statistics & numerical data