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Appl Clin Inform 2020; 11(05): 692-698
DOI: 10.1055/s-0040-1716537
Case Report

Application of Human Factors Methods to Understand Missed Follow-up of Abnormal Test Results

Deevakar Rogith
1   The University of Texas Health Science Center at Houston School of Biomedical Informatics, Houston, Texas, United States
,
Tyler Satterly
2   Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veteran Affairs Medical Center, Houston, Texas, United States
3   Department of Medicine, Section of Health Services Research, Baylor College of Medicine, Houston, Texas, United States
,
Hardeep Singh
2   Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veteran Affairs Medical Center, Houston, Texas, United States
3   Department of Medicine, Section of Health Services Research, Baylor College of Medicine, Houston, Texas, United States
,
Dean F. Sittig
1   The University of Texas Health Science Center at Houston School of Biomedical Informatics, Houston, Texas, United States
4   UT-Memorial Hermann Center for Healthcare Quality and Safety, Houston, Texas, United States
,
Elise Russo
5   Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, United States
,
Michael W. Smith
6   Department of Industrial and Mechanical Engineering, Universidad de las Americas Puebla, Cholula, Mexico
,
Don Roosan
7   Department of Pharmacy Practice and Administration, College of Pharmacy Western University of Health Sciences, Pomona, California, United States
,
Viraj Bhise
8   Department of Medicine, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, United States
,
Daniel R. Murphy
2   Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veteran Affairs Medical Center, Houston, Texas, United States
3   Department of Medicine, Section of Health Services Research, Baylor College of Medicine, Houston, Texas, United States
› Author Affiliations Funding 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.
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Abstract

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.

Keywords

contextual 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.


Supplementary Material



Publication History

Received: 04 March 2020

Accepted: 01 August 2020

Article published online:
21 October 2020

Georg Thieme Verlag KG
Stuttgart · New York

 

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