The Test Wasn't the Hard Part Understanding It Was

Introduction

A widely cited estimate from the Institute of Medicine's "To Err Is Human" report puts preventable medical error among the leading causes of death in the U.S. Not all of those errors trace back to a lab. But a meaningful share of them trace back to a result that existed, was technically correct, and still didn't reach the right person in a form they could act on.

That's the gap worth closing. Not "more testing" — better handling of the test you already ran. Taliferro builds laboratory information systems for exactly this reason: a result sitting in a database isn't the same as a result a clinician has seen and understood.

The result exists. That's not the same as anyone understanding it.

A blood test comes back with numbers. You know what they mean if you ran the test — but the ordering physician, three systems away, might not, especially at the end of a long shift. The data is technically "in the system." If it's buried in a screen full of other values with no flags, no context, and no clear next step, it might as well not be. A well-built LIS doesn't just store the result — it surfaces the one number that matters, flags it against the reference range, and routes it to the person who ordered the test instead of waiting for someone to go looking for it.

Get the result back to both the physician and the patient

Feedback matters on both ends. Patients want to know their labs were run correctly and what the numbers mean for them. Physicians need the result to know whether the current treatment plan is working or needs to change. A result that reaches only one side of that conversation is half-finished.

There are a few reliable ways to close that loop:

• A report delivered by email or portal, with the result and a link to the full record — not just a number with no context.
• Automated alerts — a call or text — the moment an abnormal result is flagged, so a critical value doesn't sit in a queue until someone happens to check.

Avoid non-standardized tests

Stick to tests that have actually been validated — by a medical board, the FDA, or an equivalent governing body. Labs aren't set up to handle tests outside that standard, and pushing one through anyway is how you end up with duplicate testing, unnecessary follow-up, and confusion about how to interpret whatever comes back.

Know what you're ordering and why

Before you place an order, be clear on what you're actually trying to learn from it. A test ordered out of habit, or "just to check," adds noise to a system that's already asking a lot of the people reading results — and noise is exactly what produces the kind of misread that leads to an error.

Ask questions when something doesn't add up

If a result doesn't match the patient's history, or you're not sure who's interpreting it or how it affects the treatment plan — ask before you act on it. The lab test isn't the finish line. Understanding what it means for this specific patient is.

Conclusion

The test is the easy part. Getting the result understood, by the right person, in time to matter, is the part that actually prevents errors — and it's the part most lab software still gets wrong.

Tyrone Showers