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Poor Test Result Communication Process Leads to Patient Injury

March 26, 2021

In the following case, a primary care practice accepted a trial offer of an electronic test result communication system from its outside laboratory. Because the office had previously relied on faxed reports from the lab, and continued to use that system during the trial, a hybrid system was in place at the time of the adverse event. Research indicates that the use of a hybrid test result system is associated with higher rates of failure to inform patients of abnormal test results compared to using a single system.1 Consider the ways in which better planning and implementation could have reduced the risk of patient injury in the following case.


More Information About Communicating Critical Findings along the Continuum of Care

Overview: Healthcare Communication: Case Studies and Best Practices for Communicating Critical Findings

Part 1: From Radiology to ED

Part 2: From Anatomic Pathologist to Ordering and Primary Care Physician

Part 3: From Primary Care Physician to Patient


Delayed diagnosis and treatment due to failure to promptly communicate abnormal results to the patient caused the patient’s injuries.

Case File

A laboratory offered a primary care clinic a free trial to use its electronic laboratory results reporting system. The system provided the physician users with access to all of their patients’ laboratory results on a portal and also automatically printed partial results on a designated printer in the physician’s office as they became available and a final report when all of the patient’s results were complete. The new system also provided a way to integrate previously faxed laboratory results into the primary care office’s electronic health record (EHR) system. (Integration was not part of the free trial.) The office manager accepted the offer. During the trial, physicians had various ways to access test results: The office continued to receive final reports by fax, and physicians had access to the portal and the partial and final reports printed out at the designated printer.

A few physicians in the practice refused to use the new system. They requested staff to only notify them when a final laboratory report was received by fax. One Friday, a series of partial laboratory results for one of the physician’s patients came through the designated printer. Some were significantly abnormal. As directed, staff held the partial results in the patient’s file. The complete report was faxed to the office the following Monday. The physician, noting the significantly abnormal results, attempted to contact the patient to advise him to go to the ED, but the patient had already sustained injuries from his untreated condition. The patient’s wife sued the physician and the clinic, alleging that delayed diagnosis and treatment caused the patient’s injury.


The defense of the physician was significantly complicated by his failure to respond to the abnormal partial results. Experts believed the patient could have avoided injury if his treatment had started two days earlier. The physician’s rejection of the new process, and the fact that the abnormal results would not have been available to him had the clinic stayed with the faxed final results system, did not excuse his failure to promptly respond to the partial results.

Risk Management Recommendations

It is important for offices to have a way to respond to test result abnormalities whenever they are delivered. Changes in processes relating to retrieving test results and promptly communicating those results to patients require careful planning, implementation, and assessment.2 Consider the following recommendations:3

  • Implement test result communication policies that reflect feedback from clinicians and staff.
  • Before making changes to test result communication processes, obtain buy-in from physicians and staff who will be using the new processes.
    • Involve clinicians and staff in changes to test result processing and communication policies and procedures.
    • Plan for the accommodation of physicians and staff who are slow adapters.
  • On a regular basis, assess the safety of your test result communication and follow-up system.
  • Conduct a safety analysis prior to instituting a new system.
This content originally appeared as part of the April 2017 release of the NORCAL Group Risk Management publication, Claims Rx, “Communicating Critical Findings — A Three-Part Series, Part 3: Primary Care Physician to Patient.” This release and many others are available in the Claims Rx Directory for download. Policyholders will also find instructions for obtaining CME credit for select releases.


1. Joanne Callen, Andrew Georgiou, et al. “The Impact for Patient Outcomes of Failure to Follow Up on Test Results. How Can We Do Better?Journal of the International Federation of Clinical Chemistry and Laboratory Medicine. 2015 Jan; 26(1): 38–46.

2. Joan Ash, Hardeep Singh, et al. “Test Results Reporting and Follow-Up.” Office of the National Coordinator for Health Information Technology (ONC). SAFER Self-Assessment Guides. Last reviewed 11/28/2018.

3. Hardeep Singh, Meena S. Vij. “Eight Recommendations for Policies for Communicating Abnormal Test Results.” Joint Commission Journal on Quality and Patient Safety. 2010 May;36(5):226-32. DOI: 10.1016/S1553-7250(10)36037-5

Filed under: Patient Care



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