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Open Access Highly Accessed Research article

The frequency of missed test results and associated treatment delays in a highly computerized health system

Terry L Wahls123* and Peter M Cram2

Author Affiliations

1 Iowa City Department of Veterans Affairs (VA) Medical Center, Iowa City, IA, USA

2 Division of General Medicine, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA

3 Center for Research in the Implementation of Innovative Strategies in Practice (CRIISP) VA HSR&D Center of Excellence, Iowa City Department of Veterans Affairs (VA) Medical Center, Iowa City, IA, USA

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BMC Family Practice 2007, 8:32  doi:10.1186/1471-2296-8-32

Published: 22 May 2007



Diagnostic errors associated with the failure to follow up on abnormal diagnostic studies ("missed results") are a potential cause of treatment delay and a threat to patient safety. Few data exist concerning the frequency of missed results and associated treatment delays within the Veterans Health Administration (VA).


The primary objective of the current study was to assess the frequency of missed results and resulting treatment delays encountered by primary care providers in VA clinics.


An anonymous on-line survey of primary care providers was conducted as part of the health systems ongoing quality improvement programs. We collected information from providers concerning their clinical effort (e.g., number of clinic sessions, number of patient visits per session), number of patients with missed abnormal test results, and the number and types of treatment delays providers encountered during the two week period prior to administration of our survey.


The survey was completed by 106 out of 198 providers (54 percent response rate). Respondents saw and average of 86 patients per 2 week period. Providers encountered 64 patients with missed results during the two week period leading up to the study and 52 patients with treatment delays. The most common missed results included imaging studies (29 percent), clinical laboratory (22 percent), anatomic pathology (9 percent), and other (40 percent). The most common diagnostic delays were cancer (34 percent), endocrine problems (26 percent), cardiac problems (16 percent), and others (24 percent).


Missed results leading to clinically important treatment delays are an important and likely underappreciated source of diagnostic error.