Errors are inevitable, and we need digital systems that understand that 

The management of clinical results is a huge part of a clinician’s daily life. It forms a key part of most patient journeys, with 95% of patient pathways involving a blood test. Hospital laboratories across England and Wales typically run over 1 billion tests every year at a cost of £2.2 billion. An average of 14 tests for each person in England and Wales are performed annually and 300,000 tests are performed every working day[1]. In Australia, the numbers are even more startling with 246,000 pathology tests performed on an average day, despite the population being less than half the size of the UK[2]. There is no doubting the scale and importance that pathology tests play in modern healthcare, and with such a volume of activity it is reasonable to suppose there will be challenges.  

As the scale and importance of pathology tests grow, so does the need to have adequate systems to ensure that we support clinicians in the timely and accurate management of those results.  

The World Health Organization has identified poor test result management as a high priority area for safety improvements[3]. Much cited systematic reviews looking into test-result follow up show that pathology and imaging results are frequently missed, with up to 62% of inpatients being impacted[4]. This figure rises to 75% of patients whose tests were undertaken in an emergency department. These omissions may not lead to harm in a significant portion of cases. However, NHS Resolution figures point to the number of people who do experience delayed diagnosis and care due to poor test result management is significant. The precise scale of clinical harm is hard to capture accurately, however data suggests the NHS litigation costs, relating to delayed diagnoses for the financial year 2021/22, could be as high as £3,051,762,587 with 70 specialties involved, including acute and community settings[5].  

The magnitude and financial implications of the issue are evident, yet the health care system is some distance away from resolving the causative factors. The cognitive burden held by our clinical workforce remains at an all-time high despite increasing digitisation of patient care. Challenges to workforce recruitment mean teams are often working with rota/roster gaps, temporary staff, or atypical shift patterns in order to maintain adequate clinical staffing. Increasingly complex patient care, against a background of rising pathology tests being requested, tell us this problem is not going to be addressed unless there are definitive steps to improve it.  

Errors are inevitable. We cannot rely on heroics from our clinical teams. We need digital solutions to act as smart companions for clinicians that make the right thing to do, the easiest thing to do. At Alcidion, when we engaged with our clinical teams, we learnt the importance of this framing. Responding to results in a timely way, in all settings, at all times, is not realistic based on the complex human factors and interdependencies of modern health care. However, it is possible to create digital safety nets that proportionally surface this risk within a digital solution so single points of failure are no longer contributing to patient harm.  

Miya Results Tracking (MRT) is built with an understanding of the complex factors that lead to a delayed response to managing results. Our Fast Healthcare Interoperability Resources (FHIR) events platform provides the technical capabilities that such a solution requires to meet clinicians’ needs. This technical capability is complemented with a user centered design approach to workflow, meaning the results tracking system is solving the problems that clinicians face in their clinical practice.  MRT creates a real time configurable interface that allows clinicians and their supervisors to filter results that have been unacknowledged and surface these results with proportional risk made evident to the user. Whilst supporting traditional results viewing capabilities such as annual leave cover, clinician sickness and more, it also allows the viewing of unacknowledged abnormal results in the context of the episode of care to allow rapid triage and action where required. This empowers clinical teams to never lose sight of the risk. We track task activity against results to ensure that once a result is understood, the action is seen through to completion.  

MRT is another example of how the Alcidion team is working closely with clinicians to solve real problems with smarter solutions. Simple to implement, yet transformative for patient safety and the working lives of our clinical teams. 

By Paul Deffley, UK Chief Medical Officer at Alcidion



[3]  Jha A. World alliance for patient safety – summary of the evidence on patient safety: implications for research. Geneva: World Health Organization, 2008:118 

[4] Callen J, Georgiou A, Li J, et al.. The safety implications of missed test results for hospitalised patients: a systematic review. BMJ Qual Saf 2011;20:194–9. 10.1136/bmjqs.2010.044339 

[5] NHS Resolution Freedom of Information request, November 2023 FOI_5716