{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,6,13]],"date-time":"2026-06-13T21:31:27Z","timestamp":1781386287853,"version":"3.54.1"},"reference-count":29,"publisher":"Georg Thieme Verlag KG","issue":"05","funder":[{"DOI":"10.13039\/100000133","name":"Agency for Health Care Research and Quality","doi-asserted-by":"crossref","award":["R01HS022087"],"award-info":[{"award-number":["R01HS022087"]}],"id":[{"id":"10.13039\/100000133","id-type":"DOI","asserted-by":"crossref"}]},{"name":"Houston VA HSR&D Center for Innovations in Quality, Effectiveness and Safety","award":["CIN 13\u2013413"],"award-info":[{"award-number":["CIN 13\u2013413"]}]},{"name":"Agency for Healthcare Research and Quality Mentored Career Development Award","award":["K08-HS022901"],"award-info":[{"award-number":["K08-HS022901"]}]},{"DOI":"10.13039\/100007217","name":"VA Health Services Research and Development Service","doi-asserted-by":"crossref","award":["CRE 12\u2013033"],"award-info":[{"award-number":["CRE 12\u2013033"]}],"id":[{"id":"10.13039\/100007217","id-type":"DOI","asserted-by":"crossref"}]},{"name":"VA National Center for Patient Safety"},{"DOI":"10.13039\/100000133","name":"Agency for Health Care Research and Quality","doi-asserted-by":"crossref","award":["R01HS022087"],"award-info":[{"award-number":["R01HS022087"]}],"id":[{"id":"10.13039\/100000133","id-type":"DOI","asserted-by":"crossref"}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Appl Clin Inform"],"published-print":{"date-parts":[[2020,10]]},"abstract":"<jats:title>Abstract<\/jats:title><jats:p>\n          Objective\u2003This study demonstrates application of human factors methods for understanding causes for lack of timely follow-up of abnormal test results (\u201cmissed results\u201d) in outpatient settings.<\/jats:p><jats:p>\n          Methods\u2003We 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.<\/jats:p><jats:p>\n          Results\u2003The 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.<\/jats:p><jats:p>\n          Conclusion\u2003This case report illustrates how human factors\u2013based approaches can enable analysis of contributing factors that lead to missed results, thus informing development of preventive strategies to address them.<\/jats:p>","DOI":"10.1055\/s-0040-1716537","type":"journal-article","created":{"date-parts":[[2020,10,21]],"date-time":"2020-10-21T22:33:17Z","timestamp":1603319597000},"page":"692-698","source":"Crossref","is-referenced-by-count":11,"title":["Application of Human Factors Methods to Understand Missed Follow-up of Abnormal Test Results"],"prefix":"10.1055","volume":"11","author":[{"given":"Deevakar","family":"Rogith","sequence":"additional","affiliation":[{"name":"The University of Texas Health Science Center at Houston School of Biomedical Informatics, Houston, Texas, United States"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Tyler","family":"Satterly","sequence":"additional","affiliation":[{"name":"Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veteran Affairs Medical Center, Houston, Texas, United States"},{"name":"Department of Medicine, Section of Health Services Research, Baylor College of Medicine, Houston, Texas, United States"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Hardeep","family":"Singh","sequence":"additional","affiliation":[{"name":"Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veteran Affairs Medical Center, Houston, Texas, United States"},{"name":"Department of Medicine, Section of Health Services Research, Baylor College of Medicine, Houston, Texas, United States"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Dean F.","family":"Sittig","sequence":"additional","affiliation":[{"name":"The University of Texas Health Science Center at Houston School of Biomedical Informatics, Houston, Texas, United States"},{"name":"UT-Memorial Hermann Center for Healthcare Quality and Safety, Houston, Texas, United States"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Elise","family":"Russo","sequence":"additional","affiliation":[{"name":"Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, United States"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Michael W.","family":"Smith","sequence":"additional","affiliation":[{"name":"Department of Industrial and Mechanical Engineering, Universidad de las Americas Puebla, Cholula, Mexico"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Don","family":"Roosan","sequence":"additional","affiliation":[{"name":"Department of Pharmacy Practice and Administration, College of Pharmacy Western University of Health Sciences, Pomona, California, United States"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Viraj","family":"Bhise","sequence":"additional","affiliation":[{"name":"Department of Medicine, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, United States"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Daniel R.","family":"Murphy","sequence":"additional","affiliation":[{"name":"Center for Innovations in Quality, Effectiveness and Safety, Michael E. 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Med"},{"issue":"02","key":"ref3","doi-asserted-by":"crossref","first-page":"194","DOI":"10.1136\/bmjqs.2010.044339","article-title":"The safety implications of missed test results for hospitalised patients: a systematic review","volume":"20","author":"J Callen","year":"2011","journal-title":"BMJ Qual Saf"},{"issue":"03","key":"ref4","doi-asserted-by":"crossref","first-page":"238","DOI":"10.1016\/j.amjmed.2009.07.027","article-title":"Notification of abnormal lab test results in an electronic medical record: do any safety concerns remain?","volume":"123","author":"H Singh","year":"2010","journal-title":"Am J Med"},{"issue":"17","key":"ref5","doi-asserted-by":"crossref","first-page":"1578","DOI":"10.1001\/archinternmed.2009.263","article-title":"Timely follow-up of abnormal diagnostic imaging test results in an outpatient setting: are electronic medical records achieving their potential?","volume":"169","author":"H Singh","year":"2009","journal-title":"Arch Intern 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Assoc"},{"issue":"06","key":"ref9","doi-asserted-by":"crossref","first-page":"e206752","DOI":"10.1001\/jamanetworkopen.2020.6752","article-title":"Assessment of health information technology-related outpatient diagnostic delays in the US veterans affairs health care system: a qualitative study of aggregated root cause analysis data","volume":"3","author":"L Powell","year":"2020","journal-title":"JAMA Netw Open"},{"issue":"03","key":"ref10","doi-asserted-by":"crossref","first-page":"282","DOI":"10.1016\/j.jacr.2018.10.015","article-title":"Classifying safety events related to diagnostic imaging from a safety reporting system using a human factors framework","volume":"16","author":"R Lacson","year":"2019","journal-title":"J Am Coll Radiol"},{"issue":"02","key":"ref11","doi-asserted-by":"crossref","first-page":"254","DOI":"10.1518\/001872098779480442","article-title":"Use of the critical decision method to elicit expert knowledge: a case study in the methodology of cognitive task analysis","volume":"40","author":"R R Hoffman","year":"1998","journal-title":"Hum Factors"},{"key":"ref12","first-page":"217","article-title":"Evidence of naturalistic decision making in military command and control","author":"R Pascual","year":"1997","journal-title":"Naturalistic Decision Making"},{"issue":"01","key":"ref13","doi-asserted-by":"crossref","first-page":"42","DOI":"10.1097\/00012272-199309000-00006","article-title":"Critical decision method: a technique for eliciting concrete assessment indicators from the intuition of NICU nurses","volume":"16","author":"B Crandall","year":"1993","journal-title":"ANS Adv Nurs Sci"},{"issue":"01","key":"ref14","doi-asserted-by":"crossref","first-page":"36","DOI":"10.1177\/1555343416629520","article-title":"Leveraging the critical decision method to develop simulation-based training for early recognition of sepsis","volume":"10","author":"M D Patterson","year":"2016","journal-title":"J Cogn Eng Decis Mak"},{"key":"ref16","doi-asserted-by":"crossref","first-page":"70","DOI":"10.1016\/j.apergo.2019.01.005","article-title":"Decision-centred design in healthcare: The process of identifying a decision support tool for airway management","volume":"77","author":"R Schnittker","year":"2019","journal-title":"Appl Ergon"},{"issue":"03","key":"ref17","doi-asserted-by":"crossref","first-page":"462","DOI":"10.1109\/21.31053","article-title":"Critical decision method for eliciting knowledge","volume":"19","author":"G A Klein","year":"1989","journal-title":"IEEE Trans Syst Man Cybern"},{"key":"ref18","first-page":"469","article-title":"Contextual inquiry: discovering physicians' true needs","author":"J Coble","year":"1995","journal-title":"Proc Annu Symp Comput Appl Med Care"},{"key":"ref19","doi-asserted-by":"crossref","first-page":"32","DOI":"10.4103\/2153-3539.122388","article-title":"Needs and workflow assessment prior to implementation of a digital pathology infrastructure for the US Air Force Medical Service","volume":"4","author":"J Ho","year":"2013","journal-title":"J Pathol Inform"},{"key":"ref20","doi-asserted-by":"crossref","first-page":"012020","DOI":"10.1088\/1757-899X\/520\/1\/012020","article-title":"The design of hemiplegia rehabilitation equipment based on contextual inquiry","volume":"520","author":"J Liang","year":"2019","journal-title":"IOP Conf. Ser.: Mater. Sci. Eng"},{"key":"ref21","volume-title":"Fault Tree Handbook","author":"W E Vesely","year":"1981"},{"issue":"01","key":"ref22","doi-asserted-by":"crossref","first-page":"87","DOI":"10.1109\/24.52616","article-title":"Fault-tree analysis for system design, development, modification, and verification","volume":"39","author":"R Hessian","year":"1990","journal-title":"IEEE Trans Reliab"},{"issue":"04","key":"ref23","doi-asserted-by":"crossref","first-page":"872","DOI":"10.1016\/j.ress.2008.09.007","article-title":"Dynamic fault tree analysis using Monte Carlo simulation in probabilistic safety assessment","volume":"94","author":"K D Rao","year":"2009","journal-title":"Reliab Eng Syst Saf"},{"issue":"05","key":"ref24","doi-asserted-by":"crossref","first-page":"339","DOI":"10.1016\/j.jlp.2004.06.004","article-title":"Semi-quantitative fault tree analysis for process plant safety using frequency and probability ranges","volume":"17","author":"U Hauptmanns","year":"2004","journal-title":"J Loss Prev Process Ind"},{"issue":"03","key":"ref25","first-page":"194","article-title":"Fault tree analysis, methods, and applications: a review. reliability","volume":"34","author":"W-S Lee","year":"1985","journal-title":"IEEE Transactions on."},{"issue":"11","key":"ref26","first-page":"598","article-title":"Using fault trees to advance understanding of diagnostic errors","volume":"43","author":"D Rogith","year":"2017","journal-title":"Jt Comm J Qual Patient Saf"},{"issue":"05","key":"ref27","doi-asserted-by":"crossref","first-page":"329","DOI":"10.1002\/jhm.2555","article-title":"Determining preventability of pediatric readmissions using fault tree analysis","volume":"11","author":"J A Jonas","year":"2016","journal-title":"J Hosp Med"},{"issue":"01","key":"ref28","doi-asserted-by":"crossref","first-page":"80","DOI":"10.1177\/1062860615614944","article-title":"Fault tree analysis: assessing the adequacy of reporting efforts to reduce postoperative bloodstream infection","volume":"32","author":"L M McElroy","year":"2017","journal-title":"Am J Med Qual"},{"key":"ref29","volume-title":"Infusion pump system safety analysis based on fault tree and Markov analysis","author":"X-Z Li","year":"2017"},{"issue":"S 03","key":"ref30","doi-asserted-by":"crossref","first-page":"i68","DOI":"10.1136\/qshc.2010.042085","article-title":"A new socio-technical model for studying health information technology in complex adaptive healthcare systems","volume":"19","author":"D F Sittig","year":"2010","journal-title":"Qual Saf Health Care"}],"container-title":["Applied Clinical Informatics"],"original-title":[],"language":"en","link":[{"URL":"http:\/\/www.thieme-connect.de\/products\/ejournals\/pdf\/10.1055\/s-0040-1716537.pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2020,10,21]],"date-time":"2020-10-21T22:33:40Z","timestamp":1603319620000},"score":1,"resource":{"primary":{"URL":"http:\/\/www.thieme-connect.de\/DOI\/DOI?10.1055\/s-0040-1716537"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2020,10]]},"references-count":29,"journal-issue":{"issue":"05","published-online":{"date-parts":[[2020,10,21]]},"published-print":{"date-parts":[[2020,10]]}},"URL":"https:\/\/doi.org\/10.1055\/s-0040-1716537","relation":{},"ISSN":["1869-0327"],"issn-type":[{"value":"1869-0327","type":"electronic"}],"subject":[],"published":{"date-parts":[[2020,10]]}}}