How should we deal with missed test results and pending results at discharge?

The failure to follow-up test results is an area of patient safety risk which can have major consequences for the quality of care, potentially leading to missed diagnoses and sub-optimal patient outcomes. Previous research has shown that pathology and imaging test results fail to be followed up in 20–62% of inpatients, and in up to 75% of patients treated in an emergency department. An investigation of reported clinical incidents undertaken by the NSW Clinical Excellence Commission in 2012 revealed that 11% (3/27) of incidents resulting in serious harm (e.g., patient death) and 32% (24/75) of incidents with major consequences for patients were related to poor test result follow-up. Health information technology (IT) has a key role to play in the communication and follow-up of test results. Effective solutions must engage all stakeholders to arrive at decisions about who needs to receive the test results, how and when the results are communicated, and how they are acknowledged and acted upon.