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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.

In the following case, a family practice patient was not advised of a significantly abnormal test result because the result came in on a Friday afternoon when no one was in the office. This situation can arise anytime an office is closed.

A pathologist’s main objectives in writing a pathology report are to communicate the diagnosis and create a permanent record.¹ The entire purpose of specimen procurement and pathology consultation may be defeated if the pathology report is inaccurate, incomplete, difficult to read, or difficult to understand.²

A list of urgent diagnoses and significant, unexpected diagnoses is an important aspect of diagnoses reporting policy. However, there is considerable disagreement about which diagnoses should be included in those lists.¹ The most relevant guideline, the “Consensus Statement on Effective Communication…” from CAP/ADASP,* does not define either urgent diagnosis or significant, unexpected diagnosis. Instead, it recommends that pathology departments develop their own lists of urgent diagnoses and provide examples of significant, unexpected diagnoses.²

A diagnosis of cancer does not always need to be directly communicated. However, special care must be used to ensure receipt of the diagnosis by the clinician in the best position to coordinate or provide treatment to the patient. The following case highlights the importance of creating a “paper trail” that proves pathology diagnoses were sent to the intended clinicians.