Risk Management Tools & Resources


Family Medicine: Addressing Clinical System Risk Factors

Clinical systems failures, a contributing factor in family medicine claims, involve breakdowns in office systems and procedures, namely tracking and follow-up systems. Technical issues — such as problems with system interfaces, user errors, software or hardware glitches, and technology failures — also can play a role in clinical system failures.

Lapses or gaps in clinical systems can lead to oversights that may ultimately contribute to medical errors and allegations of malpractice, such as failure to diagnose or delay in diagnosis.

Because clinical system failures can compromise patient safety and increase liability, every family medicine practice needs adequate systems and processes for tracking test results, consults/referrals, and patient follow-up (regarding test results, missed/cancelled appointments, etc.).

Consider your own practice. Do you have protocols in place to ensure:

  • Ordered tests are scheduled?
  • Scheduled tests are completed?
  • Test results are received by the practice?
  • The ordering practitioner reviews and initials all test results?
  • A test reporting form and patient notification process are in place?
  • Practitioners follow up on test results?
  • Test results are filed in the correct patient record?
  • Decisions about patient care are documented?

Identification of any gaps in these processes should prompt proactive measures to implement safeguards, such as establishing a mechanism to trigger immediate follow-up and reporting of critical test results, assigning staff responsibilities for follow-up activities, educating staff about their roles in various processes, and including clinical systems review as part of quality improvement initiatives.

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