___________________________________________________________________________ Risk Management
physician has reviewed the results and communicated them to the patient and the practice of notifying patients only when the results are abnormal [140]. According to one study, 7% to 26% of patients with test results were not informed of the results (or did not have documentation of notification) [153]. In another study, patient notification was documented in 58% to 85% of charts, but rates were lower for documentation of the physician’s response to the result (47% to 84%) and for follow-up after abnormal results (28% to 55%) [140; 146; 150]. A 2022 qualitative study that included 28 patients and 19 gen- eral practitioners (GPs) from six practices found that test result communication varied between the GPs and patients were based on habit, unwritten heuristics, and personal preferences rather than protocols [154]. Further, the GPs who participated in the study expected their patients to know how to access their own test results. Both the patients and physicians assumed that the other party would make contact about the results, with potential implications for patient frustration, anxiety, and safety [154]. An analysis of negligence claims involving test results management found that 14 of the 50 cases analyzed (28%) involved a delay in diagnosis or treatment of a patient with cancer; 15 (30%) were judged to be “never events;” 24 cases (48%) involved failure to notify patients of an abnormal test result; and 18 cases (36%) involved a test result not being actioned by a doctor [155]. Frequently occurring contributory factors (60%) were related to local working conditions (e.g., responsibilities, lack of patient care continuity). As noted, prompting through electronic health record systems may help alleviate this issue [146]. Physicians recognize the inadequacy of test results tracking. When surveyed, most physicians have expressed dissatisfaction with their practice’s process for tracking test results. These surveys have indicated that only 15% to 41% of physicians said they were satisfied with how test results were managed in their offices [146; 156; 157]. Physicians were most likely to be satisfied when they actively tracked test orders to comple- tion and/or used tools to help set priorities for workflow and generate letters to patients [157]. The optimum process for managing test results will vary accord- ing to a practice’s specific needs and resources, especially tech- nology. A focus on patient safety and a willingness to embrace technology throughout a practice are important factors in establishing and maintaining an effective test tracking system [150]. In the past, several practices have established systems in which staff log ordered tests in a notebook or date-defined card boxes, check them off when test results come in and again when the physician signs off on the results, and note when the patient has been notified [85; 148]. Although this system is effective, automated systems that perform the same tasks are more reliable and are less labor-intensive, a factor especially important in large practices [148]. Electronic clinical reminders are more efficient, and systems can be programmed to provide alerts when a test result is due or a patient should return for follow-up care [156]. Creating templates of patient notification
letters for the most common tests is also helpful [148]. Also available are telephone and web-based programs that allow patients to obtain their test results; privacy is ensured with the need for a password, and some programs enable the physician to include specific comments to the patient [148]. Given the high risk of malpractice claims in association with various types of cancer, physicians should also be thorough in their approach to recommending screening tests. Follow-up should be done to ensure that the patient has had the screen- ing and has been notified of the results. If the patient refuses to have screening despite the physician’s recommendation and explanation of the risks, the refusal should be clearly documented in the patient’s medical record [85]. Because appropriate follow-up after abnormal test results is often lacking, a test tracking system must involve a consistent process for scheduling follow-up visits. Failure to follow-up on abnormal mammography and ultrasound are common assertions in malpractice claims [85]. In addition, studies have shown that at least 20% to 36% of women do not receive guideline-directed follow-up after abnormal findings on mam- mography or Pap tests [158; 159; 160]. Failure to follow-up on suspicious findings on lung radiographs or computed tomography scans has also been noted [67]. Medication Management Management of patients’ medications is a frequent problem in medical office practice and a common basis for malpractice claims [64; 65; 140]. As noted earlier, a substantial proportion of medication errors and adverse drug events are considered to be preventable [64; 65]. In the office and outpatient setting, preventable medication errors occur primarily in the prescribing and monitoring stages [65; 161; 162]. Prescribing errors were identified in up to 11% of prescriptions written in the primary care setting and were typically related to dosage errors [58; 163]. Prescribing errors have also frequently involved the use of inappropriate drugs [65; 162]. Inadequate monitoring has caused a wide variety of adverse effects, such as electrolyte/renal imbalance, bleed- ing, gastrointestinal toxicity, and neuropsychiatric events, and often requires hospitalization of the patient [65; 161]. Other common medication-related errors are a failure to prescribe prophylactic agents when appropriate (as for patients taking nonsteroidal anti-inflammatory agents or anticoagulants) and drug-drug interactions [58; 161]. Studies and reviews of malpractice claims have identified several drug classes that are most often associated with pre- ventable medication errors: antibiotics, antidepressants or antipsychotic agents, cardiovascular drugs, anticoagulants, analgesics, hypoglycemic agents, and diuretics [64; 65; 161]. As with most medical errors, preventable medication errors are most frequently caused by system deficiencies [64]. Electronic prescribing systems have not been found to reduce the number of prescribing errors; for example, handwriting legibility issues
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