With an estimated 175,0001,2 pathology referrals throughout Australia every day and the likelihood of 3%3 of tests requested being missed, there is the potential for 20,000 tests not to be performed.
Marita Barnes, Executive Operations Manager, Sullivan Nicolaides Pathology, Queensland, says manual errors occurring during entry of patient details and test requests are the primary source of pathology test errors.
Being aware of the common pitfalls when ordering, reviewing and acting on pathology tests and following these tips, will ensure all tests are performed and acted on appropriately.
Avoid manually editing e-order forms
Many pathology labs now use e-ordering which allows doctors to send electronic test requests directly to the pathology lab. The e-order form generates a barcode which captures the patient, doctor and test details, as entered on the form. This is scanned at the lab to minimise transcription error.
However, problems can arise if the doctor adds to the pathology request form in handwriting or free text. In this instance, the barcode generated will only list the tests selected from the pre-populated menu options. Therefore, these additional tests won’t be detected and could be missed by the lab.
Although it’s not always practicable in a busy practice, the best way to avoid this is to only use the coded tests, either selecting from a test list or using favourites set up in the requesting screen.
If you add a test after printing the form, it is preferable to find the correct coded test and reprint the form. If this is not possible and you manually add a test to the form, then make it obvious – use a highlighter and tell the patient to point this out at the pathology lab.
Allocate time to review during the day
Doctors read many test results every day and this is usually performed outside of consulting hours, sometimes late at night, making it easy for mistakes to occur.
Doctors can minimise overload by not over-ordering pathology and only ordering relevant screening or diagnostic tests according to guidelines. Set time aside throughout the day to review pathology results to prevent the late-night syndrome and allocate time to contact patients with significant results.
Double-check results to minimise cognitive error
Expectation bias can also contribute to errors when reviewing test results. This occurs when doctors are not expecting an abnormality and therefore do not register the abnormal result.
For example, when a doctor orders a complete blood count for a middle-aged male patient with cardiovascular screening tests such as lipids and glucose, commonly, the other tests are normal and follow up is not critical. However, a Hb 115g/dL, suggestive of iron deficiency anaemia, requires follow up to investigate the cause. This can be overlooked, resulting in a later claim for delayed diagnosis of a malignancy.
Many clinical software systems help doctors by marking abnormal results with the equivalent of a red flag, alerting them to an abnormality. However, if a result is not provided in numeric format, such as written histopathology results, the system cannot detect the abnormality and the result won’t be flagged. These types of results require thorough reading and extra care.
Creating a double-check system in the practice can minimise these errors. This involves someone reviewing all the results on a daily basis as a first pass to pick up significant results quickly. Then the doctor who ordered the tests can review their own patients’ results at a later time.
Have an alert system for unreturned tests
It’s important to develop a system within your practice which alerts you when a clinically significant test result has not been returned. Doctors may not receive test results for several reasons:
- The test was never performed.
- The results were sent to the incorrect doctor or practice, or incorrect patient details were entered on the form.
- Procedural issues in the doctor’s practice led to the results being missed.
When ordering tests, explaining to the patient the need for the test and the benefits and possible risks of not having the test done can increase their understanding and encourage compliance.
Poor follow-up systems within a practice can mean patients with abnormal results are not recalled in a timely manner or in some instances, not at all. Having a reliable system in place for tracking and actioning clinically significant tests and results is essential. A key part of the process is deciding on actions when:
- a test is ordered
- a patient doesn’t present for a test within a specified time-frame
- results are received (whether normal or abnormal)
- results are not received within a specified time-frame
- results are communicated to a patient and how they are communicated
- a patient needs to be recalled to discuss results
- a patient doesn’t present to discuss results within a specific time-frame.
For more information, read our article on clinically significant test result protocol.
1Barnes M. How to avoid common pathology test pitfalls. Sullivan Nicolaides Pathology, Bowen Hills, Queensland; 2019.
2Medicare Australia - Statistics - Medicare Benefits Schedule (MBS) Item Statistics [Internet]. Medicarestatistics.humanservices.gov.au. 2019 [cited 17 October 2019].
3Barnes M. How to avoid common pathology test pitfalls. Sullivan Nicolaides Pathology, Bowen Hills, Queensland; 2019.