Preventing patients from falling through the cracks

Ms Suzanne Creed provides advice on ensuring your test result tracking system is safe

In any busy healthcare department, the number of medical investigations, such as laboratory and radiology tests requested, can be staggering. Clinicians require robust and efficient systems for the management and follow-up of test results in order to make timely and informed decisions about patient care. From a risk management perspective, it is crucial that the clinician requesting the test has an effective system in place to ensure all tests requested are returned as results and that they are reviewed and acted upon in a timely manner. Inadequate or poor communication of test results to referrers and inadequate arrangements to follow-up patients are globally acknowledged as a significant source of errors in healthcare settings worldwide.

Poor test result management can have major consequences for the quality of care of patients and their relatives, leading to delayed or missed diagnoses, prolonged hospitalisations, and suboptimal patient outcomes. Similarly, poor test result management can adversely impact healthcare staff leading to time wasted on chasing up test results, additional time spent on repeating tests, the financial burden of additional appointments, reputational damage, and the potential increase in complaints and litigation. 

Although the practice of medicine cannot always be perfect, accuracy is imperative when it comes to tracking patients’ test results. Accurate and timely tracking of results is generally achievable only if the tracking process is straightforward and comprehensive to capture all necessary information for each test requested. Then, the process must be consistently and completely performed on every single occasion. Policies that detail how the tracking system is operationalised should aim for zero tolerance in variation.

Designing the ‘tracking’ process

Process mapping is a technique that can be used when designing or implementing a quality improvement project in healthcare. This approach can help to map the whole patient journey or steps in a work process with the help of people who represent all the different roles involved. When devising or evaluating a tracking system, identifying the various steps in the process is helpful. Consider which steps of the patient’s test result journey are most prone to failures and the steps in which failures potentially could occur, such as:

• What could prevent a clinician from reviewing an important report? A possible reason is that the clinic or practice never received the report in the first place.

• Why might this occur? Perhaps the test was not requested in the first instance, or the patient failed to attend to have the testing done.

• Perhaps the specimens were lost in transit or misplaced once they arrived at the lab.

• Another possibility is that the test was completed, but the pathologist or radiologist failed to generate a report – or the report, once generated, was lost in transit.

• In hospital, what happens when a test result is returned, but the patient has been discharged? Who reviews these results, communicates them to the patient, and ensures appropriate follow-up of a result that is deemed to be significant?

A key element of a successful test result tracking system is to engage all key personnel involved in the process from the design to the implementation phase and to obtain regular feedback on what worked well and any perceived problems.

One strategy that healthcare organisations may decide to employ is assigning a staff member with the responsibility of ensuring that all reports have been reviewed (with acknowledgment by means of the clinicians’ signature or initials and date). The responsible individual could monitor the process to ensure no reports are filed prior to review and sign-off. Although this might be a labour-intensive activity, it could prove vital to the organisation’s patient safety efforts. However, it is important to be aware that overall clinical governance lies with the clinician who orders the test to ensure that the results are reviewed and communicated to the patient and the patient is appropriately followed up in a timely manner.

Accurate and timely tracking
of results is generally
achievable only if the tracking process is straightforward
and comprehensive to capture all necessary information
for each test requested

Professional obligations

All doctors have an ethical obligation to provide safe patient care. The Medical Council’s Guide to Professional Conduct and Ethics states at paragraph 64.1: “You should make sure, as far as possible, that the services and treatment you provide are safe and comply with the standards of the profession.”

Healthcare providers have a duty to recognise when they do not receive requested test result reports and that is what a patient test result tracking system is intended to help them accomplish. No single approach is necessarily “the best” patient-tracking method. Many healthcare practices prefer to use electronic systems, while others still rely on paper-based methods. What is crucial is that the method used is intuitive, capable of capturing all of the necessary data and that clinicians and staff members can adhere to it without exception.

Documentation

As with all patient interactions, it is important that all relevant details of the test result process are documented in the patient’s clinical file. Documentation should include:

• Details of the test(s) requested;

• The results of the test;

• Patient notification of the results;

• Clinical decisions based on the results.

Clinicians should document their rationale for ordering or not ordering further clinical tests and patient reviews based on the test results. These details outline the clinicians’ thought processes and efforts made to provide high-quality safe patient care. Such information may be crucial in the event of a malpractice claim or complaint. 

IT systems

Healthcare organisations that are using electronic health record systems or other technology to facilitate patient tracking should engage their IT providers to identify whether their systems can automate the process to improve timeliness and consistency. It may be feasible to have the system generate a daily task list that flags certain situations that could lead to risk exposure. Circumstances that should be flagged include:

• Tests ordered, but no results received within a reasonable timeframe;

• Test results received, but not viewed by a clinician;

• Test results viewed by a clinician, but not communicated to the patient in a timely fashion or the patient not followed up appropriately.

Routinely running reports to identify overlooked test results is also critical, even if test results are included on daily task lists.

Healthcare organisations should also consider working with their IT experts and reporting sources to devise a process in which critical test results are flagged for immediate attention. This might involve a colour-coding scheme, or other visual identifiers; the use of secure texting or email; or, preferably, calling the referring clinician.

In general practice settings, there should be arrangements in place in the event of the laboratory having a critically abnormal result requiring patient communication during out-of-hours.

Engaging patients

Finally, all clinicians should encourage patients to follow up with their healthcare organisation if they do not receive their results within a specified timeframe. The mantra ‘no news is good news’ should be changed to ‘no news is no news’. Engaging patients in the diagnostic process can provide an additional safeguard to prevent critical results from being overlooked.

In summary

With a large volume of medical investigations requested both in primary and secondary care, patient safety is dependent on healthcare organisations ensuring they have designed and implemented a robust test result tracking system. This requires ongoing input and feedback from all key personnel involved in the process. An effective test result tracking system should ensure that all tests requested are returned as results, reviewed by a clinician in a timely manner, and communicated to patients with appropriate follow-up measures in place. This can prevent your patients from falling through the cracks.

Medisec has a suite of educational resources to facilitate the safe management of test results in healthcare settings. For further information please visit the Medisec website or contact a member of the Medisec team.

References available on request

This article has been adapted with the kind permission of our business partner Medpro.