Table 5. Characteristics and number of missed opportunities that arose directly from diagnostic test result–related factors.
| Level of process breakdown | Number of patients | Number of missed opportunities | Most common setting | Most common clues | Most common personnel involved | Most common contributory factors |
|---|---|---|---|---|---|---|
| Diagnostic/laboratory test ordered but not performed | 36 | 53 | Provider office (33) | Anemia (29) | Nurse (17) | Provider: |
| Radiology (14) | Abdominal pain (9) | Primary Care (12) | No tracking mechanism for orders (26) | |||
| Patient's home (3) | Hematochezia (8) | Radiology (11) | Provider unaware test not performed (18) | |||
| Inpatient (2) | FOBT + (7) | Patient (8) | Patient: | |||
| Cancelled appt (5) | ||||||
| Missed appt (4) | ||||||
|
| ||||||
| Diagnostic/laboratory test not performed correctly | 6 | 7 | Radiology (3) | Anemia (2) | Radiology (4) | Provider: |
| Provider office (2) | FOBT + (2) | Incomplete test due to poor bowel prep (11) | ||||
| Inpatient (1) | Rectal mass (2) | Patient: | ||||
| Hematochezia (1) | None | |||||
|
| ||||||
| Diagnostic/laboratory tests not interpreted correctly | 11 | 13 | Provider office (10) | Anemia (8) | Physician assistant (5) | Provider: |
| Inpatient (2) | FOBT + (3) | Primary care (4) | Misinterpretation of test results (10) | |||
| Radiology (1) | Barium enema + (1) | Patient: | ||||
| None | ||||||