A health care professional’s failure to follow-up on abnormal diagnostic test results represents one of the most problematic safety issues in the practice of outpatient medicine.
Newsletter
Test Result Notification
Aug 31, 2013
Patient Safety Alert 15: Test Result Notification (PDF)
The AMC PSO recently held a collaborative convening session of its Ambulatory Patient Safety Leaders in order to both discuss current issues and possible solutions and propagate the natural progression of CRICO’s established mission of helping health care providers turn credible data into effective action.
Alert
A health care professional’s failure to follow-up on abnormal diagnostic test results represents one of the most problematic safety issues in the practice of outpatient medicine (Muff and Bates, 2001; Poon et al. 2003) and is an issue that has garnered national attention in the courts, the press, and among professional medical associations.
- As discussed by Poon et al. (2004), previously published peer reviewed papers examining the communication of test results to patients indicate that: 36% of clinicians do not routinely inform their patients about test results.

Download PDF Free of Charge
PDF

AMC PSO
Our Patient Safety Organization convenes clinical leaders to identify and mitigate emerging risks.
Learn with us

More AMC PSO Content
Publications such as whitepapers and guidelines derived from the AMC PSO convenings.
No Surgical Items Left Behind
Newsletter
While the occurrence is rare, Massachusetts reported rising rates of retained surgical items over the past several years.
Periprocedural Management of Anticoagulation Therapy
Newsletter
Patient Safety Alert Issue 24: The AMC PSO recently convened to discuss this high-risk area and important patient safety issue, the contributing factors often associated with this medication event type, and the strategies to proactively mitigate this risk.
Patient Falls
Newsletter
Patient Safety Alert Issue 23: The AMC PSO convened a panel of nursing leaders to review recent trends, evaluate the current literature, and discuss novel interventions aimed at mitigating the risk regarding patient falls.
Failure to Rescue
Newsletter
Patient Safety Alert Issue 22: The AMC PSO has recently assembled a panel of subject matter experts to review data, literature, and their own experiences with insufficient patient monitoring and failure to rescue.
Establishing a Regional Registry for Neonatal Encephalopathy: Impact on Identification of Gaps in Practice
News
Neonatal encephalopathy continues to be a significant risk for death and disability. To address this risk, regional guidelines were developed with the support of CRICO. A neonatal encephalopathy registry was also established. The aim of this study was to identify areas of variation in practice that could benefit from quality improvement projects.
Teleradiology Medical Malpractice Cases
News
Candello Member
This June 4, 2024, podcast by RSNA, features Dr. Francis Deng, a Diagnostic Neuroradiologist and Assistant Professor at Johns Hopkins University, who interviews CRICO’s Dr. Adam Schaffer about the characteristics of teleradiology medical malpractice cases.
Diagnostic Errors Linked to Nearly 800,000 Deaths or Cases of Permanent Disability in U.S.
News
CRICO in partnership with Johns Hopkins Armstrong Institute Center for Diagnostic Excellence, conducted a study that indicates misdiagnosis of disease or other medical conditions leads to hundreds of thousands of deaths and permanent disabilities each year in the U.S.
In the Wake of a New Report on Diagnostic Errors SIDM Invites Collaboration and Policy Action
News
A new report by CRICO and Johns Hopkins Armstrong Institute Center for Diagnostic Excellence provides the first national estimate of permanent morbidity and mortality resulting from diagnostic errors across all clinical settings. The Society to Improve Diagnosis in Medicine (SIDM) works to raise awareness of the burden of diagnostic error as a major public health issue and calls for collaboration and policy action on the issue.