Improving Your Office Testing Process

User Guide

The purpose of this toolkit is to make your office a safer place for patients by increasing the reliability of your office testing process.

You and your staff can use materials from this toolkit to take manageable steps to improve office safety and quality.


About 40 percent of patient encounters in primary care offices involve some form of medical test. Studies of primary care offices consistently show that the process for managing tests is a significant source of error and patient harm. Some errors can have devastating results, as described in this patient vignette.

A routine PSA test was ordered, along with other tests, for a 55-year-old patient. The other tests came back, but the PSA test results were lost in communications with the lab and were forgotten. The physician first noticed that the PSA test had not come back when the patient returned a year later. A new PSA test was ordered, and it returned a value of 20, indicating the patient now had metastatic prostate cancer.

Maybe you have had a similar experience in your office or know of a similar story. Errors in managing tests are more common than most of us realize.

This toolkit can help you increase the reliability of the testing process in your office. The tools will help you examine how tests are managed in your office, from the moment tests are ordered until the patient is notified of the test results and the appropriate followup is determined.

Successful practice improvement requires:

  • The desire to improve.
  • Support of office leadership for improving quality and safety.
  • Teamwork—everyone should be involved in the improvement process.
  • Commitment to honest and open communication.
  • Regular discussion of performance improvement at staff meetings.
  • A focus on office systems rather than individual performance.
  • Persistence—a promise to stick with it.
Page last reviewed August 2013
Page originally created August 2013
Internet Citation: User Guide. Content last reviewed August 2013. Agency for Healthcare Research and Quality, Rockville, MD.