Risk Management Tools & Resources


Preventing Patients From Slipping Through the Cracks


In busy healthcare practices, the number of tests and consultations that healthcare providers order can be staggering. From a risk management perspective, it is essential that ordering providers review the results of tests, examinations, and consultations and act on them — even if that only involves assuring patients that their results came back negative.

Failure to review or act on just one critical finding can have serious consequences for patients and providers. Although the practice of medicine cannot always be perfect, accuracy is imperative when it comes to patient tracking. Accurate and timely patient tracking generally is achievable only if the tracking process is simple, but also comprehensive enough to capture all necessary information for every case. Then, the process must be consistently and completely performed on every single occasion. Policies related to tracking should aim for zero tolerance in variation.

When devising or evaluating a tracking system, identifying the various steps in the process is helpful. Consider which steps are most prone to failures and the steps in which failures potentially could occur. What could prevent a provider from reviewing an important report? An obvious reason is that the office never received the report. Why might this occur? Maybe the patient failed to have the testing done. Perhaps the specimens were lost in transit or misplaced once they arrived at the lab. It is also possible that the test was completed, but the pathologist or radiologist failed to generate a report — or the report, once generated, was lost in transit.

Healthcare providers have a duty to recognize when they do not receive requested reports, and that is what patient tracking 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 is simple, capable of capturing all of the necessary data, and that providers and staff members can adhere to it without exception.

A process for identifying reports not received is just one aspect of patient tracking. Healthcare practices also need to be cognizant of tracking failures that can occur after results are received at the office. Internal processes are needed to ensure providers review and acknowledge all test results. Documentation should include:

  • The results of the test
  • Patient notification of the results
  • Clinical decisions based on the results

Ordering providers should document their rationale for ordering or not ordering further clinical steps based on the test results. This documentation establishes the practitioner’s efforts to provide quality patient care — and it might be essential in the defense of a malpractice claim.

One strategy that healthcare practices can employ is assigning a staff member with the responsibility of ensuring that all reports have been reviewed (with acknowledgment by means of the healthcare provider’s signature or initials and date). The responsible individual can monitor to make sure no reports are filed prior to review and signoff. Although this might be a labor-intensive activity, it can prove vital to the practice’s patient safety efforts.

Practices that are using electronic health record systems or other technology to facilitate patient tracking should see whether their systems can automate the process to improve timeliness and consistency. 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
  • Test results received, but not viewed by the healthcare provider
  • Test results viewed by the healthcare provider, but not communicated to the patient

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

Healthcare practices also should consider working with their reporting sources to devise a process in which critical test results are flagged for immediate attention. This might involve a color-coding scheme, letter classification, or other visual identifiers; the use of secure texting or email; or, preferably, calling the ordering provider. The approach that will prove both workable and reliable will depend on the needs of each healthcare practice.

Finally, providers should encourage patients to follow up with the healthcare practice if they do not receive their results within a specified timeframe. Engaging patients in the diagnostic process can provide an additional safeguard to prevent critical results from being overlooked and patients slipping through the cracks.

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