Failure to recognize and act on abnormal test results: the case of screening bone densitometry.

Peter Cram, Gary E. Rosenthal, Robert Ohsfeldt, Robert B. Wallace, Janet Schlechte, Gordon D. Schiff

Research output: Contribution to journalArticlepeer-review


BACKGROUND: Failure to follow up on abnormal test results is common. A model was developed to capture the reasons why providers did not take action on abnormal test results. METHODS: A systematic review of the medical literature was conducted to identify why providers did not follow up on test results. The reasons were then synthesized to develop an operational model. The model was tested by reviewing electronic medical records of consecutive patients diagnosed with osteoporosis through a dual-energy x-ray absorptiometry (DXA) scan to determine whether: (1) the scan results had been reeviewed; (2) therapy was recommended; (3) the scan results were not reviewed and why this occurred. RESULTS: Of the 48 newly diagnosed osteoporosis patients, 16 did not receive a recommendation to begin treatment. There was no evidence that the scan results wrere reviewed in 11 of the 16 cases (23% of all abnormal scans); the scan results of an additional 5 patients were reviewed but no treatment was recommended. DISCUSSION AND CONCLUSIONS: A clinically significant ercentage of DXA scan results went unrecognized. As a long-term solution, direct patient notification could theoretically reduce the burden on providers, activate and empower patients, and create a back-up system for ensuring that patients are notified of their test results.

Original languageEnglish (US)
Pages (from-to)90-97
Number of pages8
JournalJoint Commission Journal on Quality and Patient Safety
Issue number2
StatePublished - Feb 2005
Externally publishedYes

ASJC Scopus subject areas

  • Leadership and Management


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