Most doctors request a considerable number of investigations on a daily basis and how results are managed is crucial for the well-being of our patients. The Health and Disability Commissioner (HDC) frequently receives complaints around the mismanagement of results.

In MPS’s experience common themes include failing to:

• ensure that an abnormal result is recognised and acted on
• bring a significant result to the attention of the appropriate clinician
• notify a patient of the result and the need for follow-up.

This article seeks to explain basic principles for managing patient results that will help to minimise the risk of adverse outcomes for patients and subsequent complaints.

A recent case

A recent case that came before the HDC¹ has highlighted the importance of communicating and acting on abnormal results. In this case a general practitioner removed a mole from a patient’s right thigh. The histology showed melanoma in situ with adequate margins showing excision was complete. There is no documentation that the patient was informed of the histology result and the patient assumed that the result was normal because he was not contacted by the surgery.

The patient returned with a lump in the right groin two years later. An ultrasound was requested by the GP and reported as most likely a reactive lymph node; recommended was either fine-needle aspiration (FNA) or repeat ultrasound in four weeks with FNA if this further scan was abnormal. The patient was advised that the lump was benign but not advised of the follow-up recommendations of the radiologist. No follow-up scan or FNA was ordered.

Several months later the lump had increased in size and the patient saw a different GP. The patient was found to have metastatic melanoma and sadly died the following year. The HDC found the first GP to be in breach of the Code of Patient Rights for not informing the patient of the abnormal ultrasound and not following up the recommendations of the radiologist.

Managing investigations

The management of clinical investigations is a contentious issue in New Zealand practice.² The Medical Council of New Zealand has no guideline or statement on this issue, which perhaps reflects the diversity of opinion within the profession. Coles does suggest that there are common principles that most parties can agree on, which clinicians should consider following to ensure patient health and safety.³

When patients or their family are unhappy with the care they have received they will often complain to the HDC. The main role of the HDC is to ensure that the rights of health consumers are upheld. Rights 4 and 6 refer to the clinician’s responsibility in the ordering and follow-up of investigations:

RIGHT 4 Right to Services of an Appropriate Standard

(1.) Every consumer has the right to have services provided with reasonable care and skill.

(4.) Every consumer has the right to have services provided in a manner that minimises the potential harm to, and optimises the quality of life of, that consumer.

(5.) Every consumer has the right to co-operation among providers to ensure quality and continuity of services.

RIGHT 6 Right to be Fully Informed

(1.) Every consumer has the right to the information that a reasonable consumer, in that consumer's circumstances, would expect to receive, including –

(f.) The results of tests With regard to the management of investigation results, the previous Commissioner’s view of key principles in managing clinical investigations is listed in panel 1:

PANEL 1

1. At the time any test is proposed, patients have a right to be told by their doctor why the test is recommended and when and how they will be informed of the results.
2. If a doctor or medical centre has a standard practice of not notifying normal test results, patients must be informed and their consent obtained to not notifying in such circumstances.
3. It must be made clear to patients that they are entitled to be notified of all test results, and, even if they agree to be notified only of abnormal test results, they are welcome to call the medical centre and check whether their results have been received and what they are.
4. In the absence of any other such arrangement being made, when results are received by a medical centre, the patient must be informed. This is especially important if the results raise a clinical concern and need follow up.
5. A doctor is responsible for having an efficient system for identifying and following up overdue test results.

Ordering investigations

When ordering tests, clinicians are expected to explain to patients why a test is being requested and when and how the results will be communicated to them. It is common practice to only contact patients if results are abnormal. However, patients should also be made aware of their right to request their results if they wish, and told how they can do so.

Patient online portals that are currently being introduced into general practice allow patients direct access to their own results once the clinician has filed them. This will allow patients easier access to their health information. It is important to note that even with the introduction of patient portals, the HDC considers that responsibility to follow-up test results remains with the referring practitioners, not the patient.⁴

It is not uncommon for patients to delay or decide not to have the investigations recommended by their health practitioner. It is difficult for a clinician to track every investigation requested – however, where significant pathology is suspected, it is prudent for clinicians to track results to ensure that they are received and dealt with in a timely manner.⁵

MPS does see a significant number of cases where opportunities for early diagnosis of a life-threatening disease, eg, cancer, are missed, with a tragic outcome. Of particular note, due to resource limitations in the public health system, investigations requested by practitioners may be delayed. If significant pathology is suspected it is prudent to advise the patient the reason for the investigation and the timeframe in which you anticipate they will be seen. Asking the patient to then make contact if this does not occur provides an additional safety net.

Timely review and management of results

A case recently published by the HDC⁶ involved an 87-year-old man admitted to hospital with gallstone ileus. He had multiple co-morbidities and was considered to have a high risk of dying from surgery. Immediately following surgery the patient had a central line inserted under US guidance in theatre. He was then admitted to ICU. During handover to ICU the staff were advised that a chest x-ray was required to ensure correct placement of the central line. This was done later that night.

The ICU registrar was unaware that the x-ray had been taken and no clinician reviewed the films until over 24 hours later. The man deteriorated in ICU with what was thought to be aspiration pneumonia and died. Upon review of the case in the hours after his death it was then found that the chest x-ray showed a tension pneumothorax. The HDC held that this was predominantly a systems failure and found the DHB in breach of Right 4(1) and (5) of the Code of Patient Rights.

A clear policy outlining the system for review and management of results will help individual practitioners and organisations to ensure that results are seen in a timely manner. Particular attention should be given to the process in place when the requesting clinician is on leave or has moved to another location or, as in this case, gone off duty. It is essential that the clinician assuming responsibility is identified in the policy to ensure that results are managed appropriately.

In a busy schedule it is easy to see how a significantly abnormal result can be overlooked. Many clinicians work part-time, which can make review of results more difficult. To ensure patient safety, clinicians and organisations must remain especially vigilant when managing abnormal test results. To minimise the risk of human error it is prudent for clinicians to utilise methods available to them – for example, a computer task manager.⁸

Handovers

Right 5 of the Code of Patient Rights requires co-operation among providers to ensure quality and continuity of services. With regards to investigation results, when care of a patient is handed over from one clinician to another, for example between different departments within a DHB or from general practice to a specialist service, the HDC considers both clinicians to have responsibilities regarding following up investigation results – the clinician who hands a patient over is expected to review all test results to hand, document tests ordered and notify the accepting doctor of any pending test results as well as the results already to hand.⁹ A clinician who accepts care of a patient is expected to actively review results of tests already performed.¹⁰

Tests ordered by another clinician

MPS is commonly asked by our members if they are responsible for tests they did not order. The primary responsibility for following up abnormal results rests with the clinician who ordered the tests.¹¹ However, the HDC has an expectation that an abnormal result will be followed up by a treating doctor regardless of who ordered the test to avoid patients ‘falling through the cracks’.

Follow-up may involve tasking another member of the team (perhaps a nurse or junior doctor) to ensure that the result has been received and appropriately managed. Supervising consultants are expected to review all investigation results when they review a patient.12 This also applies to GPs, who may be only one of a number of clinicians to consult with a patient concerning a health problem.

Conclusion

Most clinicians order and review a vast number of tests on a day-to-day basis. Many difficulties can arise when the process of ordering and managing results is not done in a timely and appropriate manner. Implementing a clear policy will help to minimise poor outcomes for patients.

The default position is that patients must be informed of all significant test results – it is the clinician’s, not the patient’s, responsibility to ensure that this happens. The onus for follow-up of abnormal results lies with the clinician ordering the test but also with those who have responsibility for overall care of the patient.

References

1. 13HDC00031
2. St George IM 2013. The management of clinical investigations. Chapter 14 in St George IM (9ed.). Cole’s Medical Practice in New Zealand 12 edition. Medical Council of New Zealand, Wellington at p129
3. St George IM 2013. The management of clinical investigations. Chapter 14 in St George IM 9ed.). Cole’s Medical Practice in New Zealand 12 edition. Medical Council of New Zealand, Wellington at p133
4. 10HDC01419
5. 12HDC0023
6. 12HDC001133
7. 10HDC01419
8. 10HDC01419
9. 05HDC11908, 04HDC00841
10. 05HDC11908
11. 10HDC01419
12. 05HDC11908