# Measuring and Improving the Safety of Test Result Follow-Up

> **NIH VA I01** · MICHAEL E DEBAKEY VA MEDICAL CENTER · 2020 · —

## Abstract

Background: Electronic health records (EHRs) can improve communication processes but unique vulnerabilities
remain. Failure to follow-up abnormal test results (“missed results”) is a key preventable factor in diagnostic
delays in the VHA and often involves EHR-based communication breakdowns. Our work, as well as data from
root cause analyses and malpractice claims in the VA, highlights many technical and “social” (i.e., workflow,
organizational, people, and policy) variables that affect test results communication and follow-up.
Objectives: We will develop and evaluate a new program for surveillance and improvement of test results-
related diagnostic safety. This will include development, implementation, and evaluation of a change package
(i.e., a catalogue of strategies, change concepts, and action steps that guide participants in their improvement
efforts15) that identifies and addresses risks that predispose health systems to missed test results.
Unique features & Innovation: In a 2017 National Quality Forum report “Improving Diagnostic Quality and
Safety”, several measurement concepts related to test results follow-up were proposed for further development.
We developed and tested a novel electronic indicator system of triggers for missed test results, which uses
automated methods to find patients meeting specific criteria using Corporate Data Warehouse (CDW) data.
Triggers are signals that can identify patients at higher risk of harm and alert providers to review records for
potential patient safety events. Our team has used triggers to identify specific data patterns to facilitate selective
chart reviews. We have achieved reasonable positive predictive values (PPVs) and negative predictive values
(NPVs), and aim to have these tools used at the system level to measure care delays more efficiently. This
measurement system has the potential to become a near real-time surveillance system to identify patients whose
test results might have been missed. However, identifying safety deficits using triggers within the CDW is only
the first step. For these reports to result in improvements, a team (clinical or organization-based) must analyze
the data and create a feedback system to generate learning and improvements. Our change package aims to
help VA facility-based teams implement a surveillance and improvement program, ensure that safety
measurement will translate into action and help them create back-up systems to monitor diagnostic delays.
Methods: Working with 2 operational partners (NCPS and VA Primary Care), our specific aims are:
Aim 1: Develop and pilot test a “change package” (SAFER Change Package) to provide VA facilities guidance
on how to implement a surveillance and feedback program related to missed test results.
Aim 2: Evaluate if the “SAFER TRACKS” Intervention (SAFER Change Package delivered using a Virtual
Breakthrough Series [VBTS] Collaborative supplemented with automated surveillance data on test results) can
reduce missed results...

## Key facts

- **NIH application ID:** 9829045
- **Project number:** 5I01HX002439-02
- **Recipient organization:** MICHAEL E DEBAKEY VA MEDICAL CENTER
- **Principal Investigator:** HARDEEP SINGH
- **Activity code:** I01 (R01, R21, SBIR, etc.)
- **Funding institute:** VA
- **Fiscal year:** 2020
- **Award amount:** —
- **Award type:** 5
- **Project period:** 2018-10-01 → 2022-09-30

## Primary source

NIH RePORTER: https://reporter.nih.gov/project-details/9829045

## Citation

> US National Institutes of Health, RePORTER application 9829045, Measuring and Improving the Safety of Test Result Follow-Up (5I01HX002439-02). Retrieved via AI Analytics 2026-05-22 from https://api.ai-analytics.org/grant/nih/9829045. Licensed CC0.

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