Background Given the fragmentation of outpatient care, timely follow-up of abnormal diagnostic test results remains a challenge. We hypothesized that an EMR that facilitates the transmission and availability of critical imaging results through either automated notification (alerting) or direct access to the primary report would eliminate this problem. Methods We studied critical imaging alert notifications in the outpatient setting of a tertiary care VA facility from November 2007 to June 2008. Tracking software determined whether the alert was acknowledged (i.e. provider opened the message for viewing) within two weeks of transmission; acknowledged alerts were considered read. We reviewed medical records and contacted providers to determine timely follow-up actions (e.g. ordering a follow-up test or consultation) within 4 weeks of transmission. Multivariable logistic regression models accounting for clustering effect by providers analyzed predictors for two outcomes; lack of acknowledgment and lack of timely follow-up. Results Of 123,638 studies (including X-rays, CT scans, ultrasounds, MRI and mammography), 1196 (0.97%) images generated alerts; 217 (18.1%) of these were unacknowledged. Alerts had a higher risk of being unacknowledged when ordering providers were trainees (OR, 5.58;95%CI, 2.86-10.89) and when dual (more than one provider alerted) as opposed to single communication was used (OR, 2.02;95%CI, 1.22-3.36). Timely follow-up was lacking in 92 (7.7% of all alerts) and was similar for acknowledged and unacknowledged alerts (7.3% vs. 9.7%;p=0.2). Risk for lack of timely follow-up was higher with dual communication (OR,1.99;95%CI, 1.06-3.48) but lower when additional verbal communication was used by the radiologist (OR, 0.12;95%CI: 0.04-0.38). Nearly all abnormal results lacking timely follow-up at 4 weeks were eventually found to have measurable clinical impact in terms of further diagnostic testing or treatment. Conclusions Critical imaging results may not receive timely follow-up actions even when providers receive and read results in an advanced, integrated EMR system. A multidisciplinary approach is needed to improve patient safety in this area.

Background Although several types of computerized provider order entry (CPOE)-related errors may occur, errors related to inconsistent information within the same prescription (ie, mismatch between the structured template and the associated free-text field) have not been described, to our knowledge. We determined the nature and frequency of such errors and identified their potential predictive variables. Methods In this prospective study, we enrolled pharmacists to report prescriptions containing inconsistent communication over a 4-month period at a tertiary care facility. We also electronically retrieved all prescriptions written during the study period containing any comments in the free-text field and then randomly selected 500 for manual review to determine inconsistencies between free-text and structured fields. Of these, prescriptions without inconsistencies were categorized as controls. Data on potentially predictive variables from reported and unreported errors and controls were collected. For all inconsistencies, we determined their nature (eg, drug dosage or administration schedule) and potential harm and used multivariate logistic regression models to identify factors associated with errors and harm. Results Of 55 992 new prescriptions, 532 (0.95%) were reported to contain inconsistent communication, a rate comparable to that obtained from the unreported group. Drug dosage was the most common inconsistent element among both groups. Certain medications were more likely associated with errors, as was the inpatient setting (odds ratio, 3.30; 95% confidence interval, 2.18–5.00) and surgical subspecialty (odds ratio, 2.45; 95% confidence interval, 1.57–3.82). About 20% of errors could have resulted in moderate to severe harm, for which significant independent predictors were found. Conclusions Despite standardization of data entry, inconsistent communication in CPOE poses a significant risk to safety. Improving the usability of the CPOE interface and integrating it with workflow may reduce this risk.

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