The continuing problem of missed test results in an integrated health system with an advanced electronic medical record

Background: Missed results can cause needless treatment delays. However, there is little data about the magnitude of this problem and the systems that clinics use to manage test results. Methods: Surveys about potential problems related to test results management were developed and administered to clinical staff in a regional Veterans Administration (VA) health care network. The provider survey, conducted four times between May 2005 and October 2006, sampling VA staff physicians, physician assistants, nurse practitioners, and internal medicine trainees, asked questions about the frequency of missed results and diagnosis or treatment delays seen in the antecedent two weeks in their clinics, or if a trainee, the antecedent month. Results: Clinical staff survey response rate was 39% (143 of 370), with 40% using standard operating procedures to manage test results. Forty-four percent routinely reported all results to patients. The provider survey response rate was 50% (441 of 884) overall, with responses often (37% overall; range 29% to 46%) indicating they had seen patients with diagnosis or treatment delays attributed to a missed result; 15% reported two or more such encounters. Discussion: Even in an integrated health system with an advanced electronic medical record, missed test results and associated diagnosis or treatment delays are common. Additional study and measures of missed results and associated treatment delays are needed.