Risk Management _ __________________________________________________________________________
valuable time away from their patients, and 49% felt that using an electronic health records detracts from their clinical effectiveness [146]. Regardless of whether an office is paper- based or technology-based, the most important systems that should be established are standardized procedures and tools for improving diagnosis, ordering and tracking tests, and managing patient’s medications. Standardized Procedures Each task in a physician practice should be standardized to ensure that the task is carried out accurately and efficiently each time, regardless of who is performing the task [146; 147; 148]. The use of standardized procedures helps to avoid errors related to lapses in staff members’ memory or to the use of new staff. Following a standardized approach to each patient ensures consistent, high-quality care for all patients. This approach is also helpful in the event the physician does not provide comprehensive documentation for a visit. For example, if a physician forgets to document a breast examination during a female patient’s annual physical examination but uses a standardized approach that includes this examination for all women during an annual physical examination, the physician can confidently describe the care given despite the lack of documentation [97]. Establishment of standardized procedures should begin with evidence-based protocols or standing order sets for chronic diseases and vital sign checks for all patients, regardless of the nature of the visit. Flowcharts, checklists, templates, and/or automatic alerts or reminders can help ensure that standardized procedures are carried out [147; 148]. Diagnosis Given that missed or delayed diagnosis is the leading basis of malpractice suits, enhancing diagnostic accuracy is imperative. As stated earlier, diagnostic errors are usually the result of several breakdowns in the diagnostic process [57]. Physicians should develop risk management strategies that focus on the most common breakdowns in the diagnostic process. Thus, physicians should ensure that they: • Obtain a thorough history • Perform a comprehensive physical examination • Order and track diagnostic tests appropriate for a patient’s signs and symptoms • Create a proper follow-up plan • Seek additional interpretation of diagnostic tests if results are uncertain or inconclusive or seem incongruous with the patient’s condition Reviews of malpractice claims, as well as a systematic review of the literature, have shown that diagnostic errors are most often involved with atypical or nonspecific presentations, rarity of the disease, or masking comorbidities [60; 85]. For example, claims related to myocardial infarction are often associated with
no history of cardiac problems, a normal electrocardiogram, and atypical signs and symptoms [85]. Similarly, malpractice claims related to breast cancer often involve younger women (average age: 45 years). Physicians should take care not to exclude diagnoses because of nontraditional presentations or low prevalence of a condition. An inappropriate or inadequate follow-up plan has been alleged in nearly one-half of claims of misdiagnosis [57; 62]. Failure to follow-up has often involved a lack of follow-up after abnormal testing, an uncertain diagnosis, or referrals [57; 97]. In addition to providing guideline-based follow-up, physicians should seek ways to improve scheduling procedures, to check patient compliance with testing and referrals, and to track test results. Most physicians are not aware that they need help in making accurate diagnoses, which means that automatic strategies, such as clinical decision support integrated into electronic health records, may be most helpful [57; 149]. Other effective interventions include electronic prompts in response to input of certain data and automated systems for tracking test results and scheduling follow-up [57]. Documentation of the differential diagnosis in the patient’s record will reflect the physician’s thought process in determining a diagnosis, which can be helpful if a malpractice claim is made [85]. This is especially important for diagnoses at high risk for malpractice, such as cancer (especially breast cancer) and myocardial infarction. The patient’s report of symptoms should be carefully documented, as well as all tests ordered, the patient’s compliance with screening and testing, and scheduled follow-up visits. Test Ordering and Tracking Laboratory and/or imaging studies are often an integral aspect of determining a definitive diagnosis, and inadequacies in managing test results can be an important factor in enhancing the timeliness and accuracy of diagnoses. Inadequate test tracking is an important factor in medical errors, with studies of primary care patients indicating that 15% to 54% of medical errors are related to test processes [150]. Ordering and tracking test results is a complex process, and the volume and variety of tests ordered within a practice add to the challenge. Four principle steps are involved in managing patients’ test results [148; 151]: • Tracking tests until the results have been received • Notifying patients of test results • Documenting that patients were notified • Ensuring that patients with abnormal results receive the recommended follow-up care A literature review indicated that there is no clearly defined method for tracking results that is effective and efficient at each of these steps, but a task flow can be created from some “good processes” that have been defined ( Figure 3 ) [152; 153].
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MDMI1826
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