Test Tracking and Follow-Up

A 28-year-old patient presented to a primary care clinic for a routine checkup and PAP smear. When the results of the PAP smear, which were abnormal, were returned the clinic, the incorrect provider name was listed as the ordering provider, and no one followed up with the patient. The results were left in a pile of results requiring further investigation, where they were not checked for more than a year. One year later, the patient had another checkup appointment but declined a PAP smear because she thought the previous results were normal. Two years later, the patient was diagnosed with advanced stage cervical cancer. (Callahan)

This case illustrates errors that may occur during test tracking and follow-up processes in ambulatory care settings and the potential consequences for patients. Physician practices order various types of tests on a daily basis, including laboratory tests, cardiology tests, and radiology or imaging studies. Data from general ambulatory care settings indicate that primary care physicians order laboratory tests in 29% of patient visits and order imaging studies in 10% of patient visits (Hickner et al.). Because many steps and individuals are involved in the testing process, there are many opportunities for errors to occur.

This Risk Analysis focuses on processes for tracking tests that have been sent to outside laboratories or testing centers, taking appropriate action on test results when they are returned to the practice, and communicating results to patients. The Risk Analysis outlines potential errors and liability related to test tracking and follow-up, highlights claims data, and provides risk management strategies to help physician offices improve practices and processes related to test tracking and follow-up. The information in the Risk Analysis applies generally to outpatient settings, but similar strategies may be implemented in hospitals, emergency departments (EDs), and other healthcare settings where tests are ordered for patients. Some specific strategies to improve test tracking and follow-up in inpatient settings, particularly when tests are returned after the patient has been discharged, are discussed in Test Tracking in the Hospital and ED.

Because the processes related to ordering and following up on diagnostic tests are complex and involve multiple individuals—including patients, physicians, other providers, administrative staff, and laboratory personnel—there are many opportunities for errors to occur. Such errors may result in missed or delayed diagnoses or delayed interventions to improve care, thus putting patients at risk for adverse outcomes. For example, a patient may suffer a preventable heart attack because blood test results that showed elevated cardiac troponin levels were sent to the incorrect physician. Other potential consequences are duplication of services, additional...