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Communication failure — especially failure to communicate critical findings in a timely manner — can cause patient injury due to treatment delay, delayed diagnosis or misdiagnosis, or lack of follow-up, and is a frequent allegation in malpractice lawsuits. Especially in primary care practices, expedited follow-up on critical or significantly abnormal test results is a major aspect of liability risk management and patient safety.

One aspect of controlling information overload is planning for the amount of time it will take to follow up on results when a test is ordered. Appropriate follow-up requires the physician to successfully complete numerous steps (e.g., review the result, communicate it to the patient, determine a treatment plan, discuss the plan with the patient, and then facilitate the treatment plan, if necessary). Any failed step during this process can result in patient injury.

Delays in staff processing of critical and significantly abnormal results can affect various aspects of a primary care practice. The following case shows how a delay in entering results into the EHR coupled with an FP’s failure to carefully investigate the patient’s fitness for surgery can result in patient death.

“No Doc” patients (patients without primary care physicians) are often treated in the ED. In the following case, an on-call FP’s agreement to admit the patient to the family practice service, and her partner’s examination of the patient, established their responsibility for following up on results ordered by the ED physician.

Although every step in test result management is important and interrelated, patient notification errors tend to result in more adverse events.¹ Communicating a critical or significantly abnormal test result requires more than simply distributing the result to the patient. The patient should understand the criticality of the result and how to follow up. Communicating the urgency of the circumstances may require an extra effort if the patient has low health literacy or cognition deficits.