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Failure to Recognize and Act on Abnormal Test Results: The Case of Screening Bone Densitometry

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Background: Failure to follow up on abnormal test results is common. A model was developed to capture the reasons why providers did not take action on abnormal test results.

Methods: A systematic review of the medical literature was conducted to identify why providers did not follow up on test results. The reasons were then synthesized to develop an operational model. The model was tested by reviewing electronic medical records of consecutive patients diagnosed with osteoporosis through a dual-energy x-ray absorptiometry (DXA) scan to determine whether: (1) the scan results had been reviewed; (2) therapy was recommended; (3) the scan results were not reviewed and why this occurred.

Results: Of the 48 newly diagnosed osteoporosis patients, 16 did not receive a recommendation to begin treatment. There was no evidence that the scan results were reviewed in 11 of the 16 cases (23% of all abnormal scans); the scan results of an additional 5 patients were reviewed but no treatment was recommended.

Discussion and Conclusions: A clinically significant percentage of DXA scan results went unrecognized. As a long-term solution, direct patient notification could theoretically reduce the burden on providers, activate and empower patients, and create a back-up system for ensuring that patients are notified of their test results.

Document Type: Research Article

Publication date: February 1, 2005

More about this publication?
  • Published monthly, The Joint Commission Journal on Quality and Patient Safety is a peer-reviewed publication dedicated to providing health professionals with the information they need to promote the quality and safety of health care. The Joint Commission Journal on Quality and Patient Safety invites original manuscripts on the development, adaptation, and/or implementation of innovative thinking, strategies, and practices in improving quality and safety in health care. Case studies, program or project reports, reports of new methodologies or new applications of methodologies, research studies on the effectiveness of improvement interventions, and commentaries on issues and practices are all considered.

    Also known as Joint Commission Journal on Quality Improvement and Joint Commission Journal on Quality and Safety
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