Application of Human Factors Methods to Understand Missed Follow-up of Abnormal Test ResultsFunding This project is funded by the Agency for Health Care Research and Quality (R01HS022087) and partially funded by the Houston VA HSR&D Center for Innovations in Quality, Effectiveness and Safety (CIN 13–413). D.R.M. is additionally funded by an Agency for Healthcare Research and Quality Mentored Career Development Award (K08-HS022901) and H.S. is additionally supported by the VA Health Services Research and Development Service (CRE 12–033; Presidential Early Career Award for Scientists and Engineers USA 14–274), the VA National Center for Patient Safety, and the Agency for Health Care Research and Quality (R01HS022087). These funding sources had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, or approval of the manuscript. There are no conflicts of interest for any authors.
Objective This study demonstrates application of human factors methods for understanding causes for lack of timely follow-up of abnormal test results (“missed results”) in outpatient settings.
Methods We identified 30 cases of missed test results by querying electronic health record data, developed a critical decision method (CDM)-based interview guide to understand decision-making processes, and interviewed physicians who ordered these tests. We analyzed transcribed responses using a contextual inquiry (CI)-based methodology to identify contextual factors contributing to missed results. We then developed a CI-based flow model and conducted a fault tree analysis (FTA) to identify hierarchical relationships between factors that delayed action.
Results The flow model highlighted barriers in information flow and decision making, and the hierarchical model identified relationships between contributing factors for delayed action. Key findings including underdeveloped methods to track follow-up, as well as mismatches, in communication channels, timeframes, and expectations between patients and physicians.
Conclusion This case report illustrates how human factors–based approaches can enable analysis of contributing factors that lead to missed results, thus informing development of preventive strategies to address them.
Keywordscontextual inquiry - fault tree analysis - abnormal laboratory follow-up - human factors - patient safety
Protection of Human and Animal Subjects
The study was approved by Baylor College of Medicine Institutional Review board. Informed consent was obtained from the physicians prior to the interview.
Received: 04 March 2020
Accepted: 01 August 2020
21 October 2020 (online)
Georg Thieme Verlag KG
Stuttgart · New York
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