Avoiding a 'near hit'

Clinical Risk Programme Manager Julie Price shares simple tips for handling test results

Dr Murphy, I came to see you two months ago and am still feeling unwell. I saw the nurse for the blood tests you ordered and phoned for the results a few days later as requested; the receptionist told me they were all normal so I don’t understand why I feel so tired?”

Dr Murphy reviewed Miss Y’s computer record, accessing the results of her blood test. Most of the results were normal but there was one showing abnormalities – the thyroid function test (TFT). Dr Murphy knew immediately what had happened. He had brought up the issue of relying on the patient to telephone the practice for their results many times. Miss Y had telephoned after a few days, but the TFT results took longer to be returned.

Dr Murphy explained the oversight to Miss Y, offering an apology. He diagnosed primary hypothyroidism and prescribed thyroid replacement therapy. “Phew,” he thought. “No harm done then, but a near miss, or perhaps more accurately a near hit.” Dr Murphy discussed this error with the other GPs over coffee later that morning. He knew the practice test result system was flawed.

Is the system you have at your practice robust, effective and safe?

Practices use the laboratory services on a daily basis, sending off specimens and receiving results which are checked for abnormalities and actioned as necessary. Is the system you have at your practice robust, effective and safe? When was the last time a test result was lost or not conveyed to a patient? Can you be sure that there are no reports in the system that you have not seen or acted upon?

Like many risks in general practice the effective management of test results is threatened by both lack of robust systems and human error. Well-designed test results systems can trap human errors and help reduce the likelihood of adverse events, thus preventing harm to patients.

An MPS study¹ found that approx 60% of claims in general practice handled by MPS related to failure to diagnose. Many of these can be attributed to system error, eg, test result abnormal but not acted on, test result scanned into wrong patient record, or an abnormal result not communicated to the patient.

What are the risks?

MPS undertakes Clinical Risk Self Assessments (CRSAs) of general practices to identify risks and develop practical solutions to prevent harm to patients. Over the past nine years MPS has conducted more than 1,100 CRSAs across the UK and Ireland. The data collected analysing the results of over 150 CRSAs conducted during 2013 reveals that 88% of practices visited had risks associated with their test results system. Figure 1 highlights the key risk areas.

Figure 1: Test result risk (% of practices visited with this risk):

No tracker system to ensure follow up

The GP might have identified a suspicious symptom, wish to reexamine the patient, or review the patient’s symptoms when test results are available. There might not be a reliable method of checking that the patient has attended his/her follow-up appointment, which may lead to a delay in diagnosis. Introducing either a manual or computerised “tracking system/log” allows the GP to track patients who require monitoring or follow-up.

The tracker log allows clinicians to enter patients they are particularly concerned about (a brain scan, for example, or a rising PSA level). Fortnightly or monthly, a nominated receptionist collects the logs and checks that the patient has attended for follow-up; if not, the GP is notified. An alternative is to use your electronic messaging system and send a task to yourself for two, three, or four weeks’ time. The log could look something like Figure 2.

Figure 2

Avoiding near hit figure 2

*only the first three columns are filled in by the GP

Figure 3 (right): Example of a multiple test sheet

No record of tests requested and no way to ensure all tests have been reported on

One of the challenges is ensuring that all samples sent to the laboratory are returned as results. Practices may consider undertaking an audit of “ins and outs” of patient samples sent to the laboratory, including blood tests and microbiology samples, to ensure that all results are returned. Some computer software programmes now have an electronic pathology test requesting system. This is a reliable method of tracking ins and outs, allied to barcode identification of samples and requests.

No test result protocol

All practices should discuss and draw up a test results protocol which includes: testing, processing the results and actioning. The protocol should be read and signed by all relevant members of the practice.

No system for dealing with multiple tests

The patient should be informed about how many tests will be carried out. Consider providing patients with a list of the samples that they have had taken, along with the usual timescale (see Figure 3).

Patient not informed of abnormal result

Responsibility for actioning results lies with the practice. Practices must develop a proactive system for dealing with abnormal results, minimising the risk of a test result being overlooked. It should not be assumed that the patient will phone up the practice to find out if any action is necessary following tests, as many will not do so for a variety of reasons.

For those who repeatedly do not attend appointments the practice needs to demonstrate that it has tried as hard as any group of competent colleagues in trying to persuade the patient to attend. Record all attempts. It is important to remember that some patients may be less able to take responsibility for their health than others, for example, those with learning difficulties, or mental illness. Do not file a result unless it has been actioned.

Practices must develop a proactive system for dealing with abnormal results, minimising the risk of a test result being overlooked

Normal results may prompt an action as well as abnormal results, for example, a patient with a normal ferritin result may be in a position to cease iron therapy. Similarly, if the hospital has asked the GP to follow up results, whether copied or not, the GP should ensure that the results are obtained and appropriate action taken.

Giving out the incorrect result

Prior to giving out a test result, confirm the patient’s identity using three identification markers, eg: name, address, date of birth. Clarify the nature of the test results and the date on which they were taken. Encourage patients to keep their contact details up-to-date – referral is an ideal time to confirm details.

Non-clinical staff entering into clinical discussion about the results

Reception staff should not enter into any clinical discussion about the results but simply read out the doctor’s comments, which should be clear and unambiguous so that the receptionist is less likely to be asked further questions by the patient. If further discussion is needed, a telephone appointment should be made with the doctor.

Some results should always be conveyed by the doctor (for example, malignancies, HIV tests). Consider developing a traffic light system:

Green results are those that can be conveyed by the receptionist, practice nurse or GP
Amber results are those that can be conveyed by either the practice nurse or GP
Red results are those that can be conveyed by the GP only.

No “buddy” system if GP away

A buddy system should be in place so that results are not missed when staff are absent from the practice. This ensures that no urgent abnormal results are overlooked, or a necessary immediate response is delayed.

A buddy system should be in place so that results are not missed when staff are absent from the practice

Clinical staff not reviewing all results

In 6% of the practices visited, the clinician only reviewed test results marked as abnormal owing to time constraints. All other results were sent to the patients’ records unread. This system is unsafe. Clinicians should review all test results.

Blood test ordered, not recorded onto the computer

To ensure continuity of care, it is essential that all tests requested are recorded in the patient’s computer record, by the clinician at the point of ordering and by type, eg, FBC U&Es tc. Entering ‘for normal bloods’ is not good practice.

What should staff do if someone other than the patient answers the phone when they try and relay a test result?

Any communication about test results should only be transmitted to the patient and not to relatives or others without the patient’s consent. Develop a simple consent form which would give permission for a relative (of, for example, an elderly patient) to be able to discuss certain issues with the practice on the patient’s behalf, eg, test results, repeat prescriptions. This form, once completed by the patient, should be scanned into the patient’s record and a note made on the computer so that it is visible when a family member speaks to the practice.

Finally

Any communication about test results should only be transmitted to the patient and not to relatives or others without the patient’s consent

Your practice should have a robust and effective test result system and all staff should be fully trained in the procedure. However, no system is ever foolproof. If an adverse event or ‘near hit’ does occur, the protocol should be reviewed and lessons learnt to prevent a repeat occurrence.

If you are interested in having a CRSA at your practice, please contact MPS Educational Services on +44 (0) 113 241 0624, email: [email protected], or visit the MPS website for more information.

Reference

Silk N, What went wrong in 1,000 negligence claims? Health Care Risk Report(2000).

Well-designed test result systems can trap human errors and help reduce the likelihood of adverse incidents, thus preventing harm to patients

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