Given the number and variety of tests carried out in the fast-paced environment of a pathology laboratory, it’s not surprising that tests occasionally slip through the cracks. These tests that are requested by a doctor but not performed by the pathologist, commonly known as ‘missed tests’, are usually discovered when the doctor makes a follow-up call to check on the result.
A call to Avant’s Medico-legal Advisory Service highlighted this problem and the dilemma that can occur when the doctor fails to check on the requested test.
The ‘perfect storm’
An obstetrician had referred a pregnant patient who was Rh (D) negative to a pathology practice for a Kleihauer test to detect transplacental haemorrhage (TPH). Weeks after the referral, the obstetrician called the pathology practice to ask why the test had not been performed. An investigation revealed that the test was not performed due to two mistakes which created a perfect storm. A pathologist had accidentally checked off that the test had been completed, and there was a system failure related to the test being incorporated with another test on the request form.
Reporting results in a timely manner is critical for proper patient care. Relying on the referring doctor’s follow-up as a safety net to detect tests not performed is not ideal. A review of 12 studies by Australian researchers indicates failure to follow up test results in a hospital setting is a substantial problem. A lack of follow-up of test results for inpatients ranged from 20.04% to 61.6%. Given that follow up by the attending doctor can be uncertain, a pathology provider should have checks in place to detect missed tests.
Once a test reaches a pathology practice, there are many points at which human error and system failures can result in a missed test. The challenge is significant, requiring careful attention at each point of the process.
Reduce the chance of missed tests: before the laboratory
The collection of specimens and entry of tests into a pathology laboratory’s information system involves a significant amount of human input and judgment, making this stage quite vulnerable to human error.
The risk of error at these early stages can be reduced by:
- Ensuring procedures and systems are in place to minimise human error (for example, marking off procedural checklists and reconciling test numbers).
- Training all staff so they are competent in following the procedures and using the systems.
- Ensuring a thorough approach to the collection and management of information (for example, doctors may inadvertently place test requests outside the relevant section of the request form and staff should be trained to examine the whole of the request form).
- Using e-ordering. This requires doctors to transmit a request directly to the pathology laboratory’s test management system via desktop software, bypassing several points of human input.
Reduce the chance of missed tests: at the laboratory
Once a test is entered into a pathology laboratory’s information system, there is little possibility of it being missed if the system is functioning properly and the pathologist is skilled in managing and monitoring the system.
Pathologists should ensure the system they are using includes a feature which highlights overdue tests. A staff member must be responsible for reviewing the list of overdue tests and following up each identified test until it is found or re-ordered.
Ongoing systems review
One of the most important factors in avoiding missed tests is having a robust test management system in place. Continually monitoring the effectiveness of these systems is a useful strategy to minimise risk.
Auditing a sample of request forms each day can help to identify problems and gaps in training, allowing the ongoing refinement of management systems and targeted training of staff.
Pathologists have a shared responsibility, along with referring doctors, to avoid missed tests. However, pathologists are responsible for all tests carried out, including those carried out under their supervision, and must ensure the effectiveness of the systems they rely on in carrying out their work.
- Ensure systems and procedures are in place to minimise human errors, including the uptake of e-ordering where possible.
- Provide training to ensure all staff know how to follow the systems and procedures.
- Monitor the effectiveness of your systems to identify any problems.
Read our Risk IQ case study ‘Out of hours pathology results’.
Share your view
We welcome your feedback on this article – email the Editor at: firstname.lastname@example.org