Research Activities, November-December 2013
From the Director
Lost or over-looked results and lack of timely follow-up on laboratory test findings can all contribute to patient care that doesn't meet quality standards important to both patients and health care providers. In particular, when test results are abnormal or suggest further testing is required, communication gaps can cause patient harm due to missed or late diagnoses or treatment. In fact, nearly a quarter of all medical errors in ambulatory care settings are due to inadequate followup of abnormal test results (http://www.ncbi.nlm.nih.gov/pubmed/18519626).
Unfortunately, errors in managing laboratory tests are frequent, and researchers are still learning about the impact this has on patient care. AHRQ's toolkit, "Improving Your Office Testing Process: Toolkit for Rapid-Cycle Patient Safety and Quality Improvement," aims to remedy the problem by increasing the reliability of the testing process in medical offices.
The toolkit (http://go.usa.gov/WZxH), described on this month's cover, was developed by a team of researchers led by Milton "Mickey" Eder, Ph.D., director of research and evaluation at Access Community Health Network in Chicago, a large network of Federally Qualified Health Centers. The toolkit includes seven tools to help health care teams assess and improve how medical tests are managed in their offices, from the moment tests are ordered until patients are notified of the test results and monitored during appropriate followup care.
This toolkit is part of AHRQ's efforts to expand its successful safety improvement initiatives in the hospital setting to ambulatory care settings and to produce evidence-based tools for use in activities such as the Department of Health and Human Services' (HHS) Partnership for Patients (PfP). The PfP initiative is a public-private partnership working to improve the quality, safety, and affordability of health care for all Americans. As part of the initiative, doctors, nurses, hospitals, employers, patients, and Federal and State governments have joined together to implement strategies to reduce healthcare-acquired conditions and avoidable readmissions to hospitals.
Lessons learned from PfP have important implications for care in other settings, including medical offices. For example, an increased focus on medical test management can help to reduce hospital readmissions by bridging gaps in care coordination. Improving the quality and safety of health care requires using a variety of tools across all settings of care—work that AHRQ in tandem with HHS and others remains committed to achieving.
Richard Kronick, Ph.D.