• Laboratory medicine
• Patient satisfaction
• Patient safety

To quote Voltaire by way of Spider-Man, with great power comes great responsibility. This phrase rings especially true for medical trainees on reaching the point in their training when they can order tests without seeking sign off from supervisors. However, they quickly learn that ordering tests is the easy part; managing the resulting data becomes the far more challenging task. Failure to follow-up on test results represents a critical breakdown point in the diagnostic process.1 The inherent complexity of test result management, which involves countless steps and handoffs between patients, physicians, nurses and ambulatory office and laboratory staff, is susceptible to failure at multiple provider-level and system-level decision points. Not surprisingly, most primary care physicians express dissatisfaction with their methods for tracking test results,2 ,3 and a substantial percentage admit to having no method at all.4 Delays in reviewing test results commonly occur,3 and approximately one in five errors in the testing process result in patient harm.5

Two articles published in BMJ Quality & Safety remind us just how much work remains to achieve a safe and reliable test result management process.6 ,7 In the first of these articles, Litchfield and colleagues6 conducted a telephone survey of 50 primary care practices in England to evaluate the process of managing and communicating test results. They found that 40% of practices required patients to call for abnormal results, and that the large majority of practices had no system in …