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Problems with laboratory tests appear to be rare but when they do occur, a substantial percentage could have a significant impact on patient care. Researchers collected data on laboratory problems associated with patient visits from 124 primary care physicians at 49 practices enrolled in the Ambulatory Sentinel Practice Network in a six-month period. A total of 180 laboratory problems were reported, which is a rate of 1.1 laboratory problems per 1,000 patient visits. However, tests are ordered in only one-third of all patient visits, making the true rate 3.4 problems per 1,000 patient visits that include a test. Forty-nine (27%) of the problems affected patient care and ten problems had a significant impact on patient care. They included lost Pap smears that required a second visit, a false negative urine culture that caused a delay in treatment and a delayed report on potassium levels that caused the patient to be hospitalized for low blood potassium., Objective.--To examine the frequency and characteristics of problems in laboratory testing in primary care physicians' offices and their impact on health care. Design.--Prospective descriptive study in which participating office-based primary care clinicians reported each occurrence of any laboratory incident during a 6-month study. Each identified problem was reported on a structured data collection instrument with an open-ended description of the problem. Sefting.--Primary care physicians' offices in North America. Participants.--One hundred twenty-four primary care clinicians in 49 practices of the Ambulatory Sentinel Practice Network (ASPN). Main Results.--A total of 180 problems were reported, yielding a crude rate of 1. 1 problems per 1 000 patient visits. Problems involving test ordering and specimen handling were the most common 56%), while those attributable to the test analysis itself accounted for 13% of the total. In the judgment of the practice staff, 27% of the reported problems had an impact on patient care. Of the 24 cases for which the specific impact was known and reported, half of the impacts were minor and about half were significant, as judged by whether or not the diagnosis and/or treatment of the patient was measurably affected. Conclusions.--Clinically apparent problems with laboratory testing in primary care were found at a rate of 1.1 problems per 1000 patient visits. Of the laboratory problems that occurred in this study, 27% were judged by the physician to have an effect on patient care. (JAMA 1996;275:635-639)