Tracking Lab Test Results and timely follow-up by your physician in terms of reviewing and acting upon all concerning outpatient tests is of paramount importance in avoiding medical errors.
According to the American College of Obstetrics and Gynecology (ACOG), every physician’s office should have the appropriate procedures in place to ensure that patient’s results are obtained for each test ordered.
According to Dr. Karen L. Bruden, a member of ACOG’s Committee on Quality Improvement and Patient Safety, OB/GYN offices should be able to answer the following questions about their lab and testing tracking systems to ensure patient safety:
“1. Is a log kept of all cytology samples submitted to different labs? By whom? 2. Is there a mechanism for tracking delayed reports or those that were never received? 3. As a secondary safety net, are all patients instructed to contact the office regarding Pap results within a specific time period? 4. Who is responsible for receiving the cytology reports? 5. Does the physician see and initial all reports before they are filed in the patient’s chart? 6. Is the cytology report attached to the chart at the time it is triaged by the physician (rather than put in a stack of “loose” reports)? 7. Are all reports triaged by the physician, or only abnormal reports? 8. If the physician reviews only the abnormal reports, who determines what constitutes an abnormal report? Are there written guidelines for the office staff? 9. What are the level of education and qualifications of nonphysician office staff who participate in the triage process? RN? LPN? colposcopy nurse? medical assistant? clerk? 10. Does the office have a “no-show” policy and mechanism in place? 11. At the end of the workday does the physician personally review the medical record of all patients who “no-show?” 12. Who is responsible for the recall of patients with abnormal cytology? Is a log kept to ensure that the patient was seen and the abnormal results addressed? 13. Is there a policy for the recall of patients who are not accessible by telephone? 14. Does the laboratory have a policy for notifying the clinician about abnormal results? 15. Is there a system for the physician to discuss results directly with the pathologist if needed?”
For more information on this topic, please visit the ACOG website for more information regarding patient safety issues. The reader may also read more about this in the January 2006 policy statement issued by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO).