title: An initiative to improve the management of clinically significant test results in a large health care network.
abstract: BACKGROUND
  The failure of providers to communicate and follow up clinically significant test results (CSTR) is an important threat to patient safety. The Massachusetts Coalition for the Prevention of Medical Errors has endorsed the creation of systems to ensure that results can be received and acknowledged.
  
  
  METHODS
  In 2008 a task force was convened that represented clinicians, laboratories, radiology, patient safety, risk management, and information systems in a large health care network with the goals of providing recommendations and a road map for improvement in the management of CSTR and of implementing this improvement plan during the sub-force sequent five years. In drafting its charter, the task broadened the scope from "critical" results to "clinically significant" ones; clinically significant was defined as any result that requires further clinical action to avoid morbidity or mortality, regardless of the urgency of that action.
  
  
  RESULTS
  The task force recommended four key areas for improvement--(1) standardization of policies and definitions, (2) robust identification of the patient's care team, (3) enhanced results management/tracking systems, and (4) centralized quality reporting and metrics. The task force faced many challenges in implementing these recommendations, including disagreements on definitions of CSTR and on who should have responsibility for CSTR, changes to established work flows, limitations of resources and of existing information systems, and definition of metrics.
  
  
  CONCLUSIONS
  This large-scale effort to improve the communication and follow-up of CSTR in a health care network continues with ongoing work to address implementation challenges, refine policies, prepare for a new clinical information system platform, and identify new ways to measure the extent of this important safety problem.
authors.affiliation: Brigham and Women's Hospital, Boston, USA. croy@partners.org
authors.forename: Christopher L
authors.initials: CL
authors.lastname: Roy
authors.forename: Jeffrey M
authors.initials: JM
authors.lastname: Rothschild
authors.forename: Anand S
authors.initials: AS
authors.lastname: Dighe
authors.forename: Gordon D
authors.initials: GD
authors.lastname: Schiff
authors.forename: Erin
authors.initials: E
authors.lastname: Graydon-Baker
authors.forename: Jennifer
authors.initials: J
authors.lastname: Lenoci-Edwards
authors.forename: Cheryl
authors.initials: C
authors.lastname: Dwyer
authors.forename: Ramin
authors.initials: R
authors.lastname: Khorasani
authors.forename: Tejal K
authors.initials: TK
authors.lastname: Gandhi
mesh_terms: D015746:Abdominal Pain / Q000000981:diagnostic imaging; D041881:Cholecystitis, Acute / Q000175:diagnosis; D003266:Continuity of Patient Care; D057210:Delayed Diagnosis; D019937:Diagnostic Techniques and Procedures / Q000592:standards*; D005260:Female; D006801:Humans; D033162:Incidental Findings; D033181:Information Dissemination / Q000379:methods; D033183:Interdisciplinary Communication; D008404:Massachusetts; D019300:Medical Errors / Q000517:prevention & control*; D008875:Middle Aged; D009362:Neoplasm Metastasis; D010051:Ovarian Neoplasms / Q000175:diagnosis; D061214:Patient Safety; D010386:Pelvic Neoplasms; D014057:Tomography, X-Ray Computed