J Am Med Inform Assoc 17:104-107 doi:10.1197/jamia.M3294
  • Original Investigation
  • Case report

Unintended errors with EHR-based result management: a case series

  1. Peter J Embi2
  1. 1Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland, Oregon, USA
  2. 2Department of Medicine and Center for Health Informatics, University of Cincinnati, Cincinnati, Ohio, USA
  1. Correspondence to Dr T R Yackel, Department of Medical Informatics and Clinical Epidemiology, OHSU, 3181 SW Sam Jackson Park Road, Mail Code: BICC, Portland, OR 97239, USA; yackelt{at}
  • Received 4 June 2009
  • Accepted 21 October 2009


Test result management is an integral aspect of quality clinical care and a crucial part of the ambulatory medicine workflow. Correct and timely communication of results to a provider is the necessary first step in ambulatory result management and has been identified as a weakness in many paper-based systems. While electronic health records (EHRs) hold promise for improving the reliability of result management, the complexities involved make this a challenging task. Experience with test result management is reported, four new categories of result management errors identified are outlined, and solutions developed during a 2-year deployment of a commercial EHR are described. Recommendations for improving test result management with EHRs are then given.


  • Funding PJE's contributions to this manuscript were supported in part by a grant from the National Institutes of Health (UL1-RR-026314).

  • Competing interests None.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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