Table 6. Characteristics and number of missed opportunities that arose directly from follow-up-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 results not followed up	60	97	Provider office (91)	Anemia (62)	Primary care (38)	Provider:
			Emergency room (3)	FOBT + (28)	Physician assistant (22)	No evidence of follow-up despite post-test visit (81)
			Inpatient (3)			Failed transmission of result to clinician (16)
						Inadequate test-result tracking system (14)
						Patient:
						Missed/cancelled appt (4)
Problems with follow-up plans	27	37	Provider office (26)	Anemia (14)	Patient (11)	Provider: Provider selected wrong interval for follow-up (13)
			Patient (9)	FOBT + (8)	Primary Care (10)	Follow-up appt not scheduled (11)
			Emergency room (1)	Abdominal pain (7)	Physician assistant (7)	Patient: Missed/cancelled appt (18)