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New AHRQ Toolkit Helps Make Care Safer for Patients in Medical Offices

Focus on preventing problems with managing lab tests and results
Press Release Date: September 16, 2013

A toolkit to help doctors, nurses and medical office staff improve their processes for tracking, reporting and following up with patients after medical laboratory tests was released today by the U.S. Department of Health and Human Services' Agency for Healthcare Research and Quality (AHRQ). The toolkit is part of the agency's effort to make care safer for patients in all settings.

Approximately 40 percent of primary care office visits involve some type of diagnostic medical test, such as a urine sample or blood test, provided on site or at a laboratory. However, if test results are lost, incorrect or incomplete, the wrong treatment may be prescribed and patient harm can occur.

"AHRQ has a strong track record of developing tools that have helped hospitals measurably improve the safety of care," said Jeff Brady, M.D., associate director of AHRQ's Center for Quality Improvement and Patient Safety. "This new toolkit is designed to improve safety in office-based settings by giving doctors and their staff a practical, easy-to-use resource to help manage their lab test results and patient follow-up."

Improving Your Office Testing Process: Toolkit for Rapid-Cycle Patient Safety and Quality Improvement ( offers step-by-step instructions on how to evaluate an office testing process, identify areas where improvement is needed and address those areas. Practical tools are included that can be used to assess office readiness, plan activities, engage patients, audit efforts and incorporate electronic health records. The toolkit also includes a template for practices to ensure that laboratory test results are communicated effectively to patients in English or Spanish.

The toolkit was developed by a team of researchers, led by Milton "Mickey" Eder, Ph.D., director of research and evaluation at Access Community Health Network in Chicago, a large network of community health centers. A national panel of primary care experts contributed, and the toolkit was tested in the Access network.

"The toolkit was developed in a network of federally qualified health centers, but studies indicate that all types of primary care offices experience problems managing tests. Clinicians and staff  handle a lot of lab test results, and unfortunately mistakes happen," said Dr. Eder. "Results can get lost or misreported or patients may not understand how to follow up, and sometimes these mistakes can have serious consequences. This toolkit has already been demonstrated to make processes safer at Access, and we're confident that doctors nationwide will see similar results by using the toolkit."

To order a free copy of  Improving Your Office Testing Process: Toolkit for Rapid-Cycle Patient Safety and Quality Improvement, contact the AHRQ Clearinghouse at 800-358-9295 or Email and ask for publication number 13-0035.

Page last reviewed September 2013
Page originally created September 2013
Internet Citation: New AHRQ Toolkit Helps Make Care Safer for Patients in Medical Offices. Content last reviewed September 2013. Agency for Healthcare Research and Quality, Rockville, MD.


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