Handle with care

AS a practice manager it is likely that you will be responsible for overseeing the effectiveness and safety of clinical systems. In the absence of standardised results management systems within primary care, practices often develop their own processes for managing tests and results. This has commonly resulted in systems that lack clarity on clinical and non-clinical boundaries and responsibilities, and can create conditions within which a number of errors may occur.

Here I highlight three of the most common risks associated with results handling systems. Mismanagement of results can have serious implications on patient safety and lead to adverse events, complaints and claims, but there are strategies to reduce risk.

RISK 1: MULTIPLE OR MISSING RESULTS

Consider the case of a patient who attends a practice with symptoms which a GP decides warrant further investigation. The patient is referred to a treatment room nurse for blood tests to be undertaken. Once the bloods are taken, the patient is asked to contact the practice later that week to receive his results.

The patient phones the practice as requested and a receptionist checks that the results are back and tells the patient that the GP has marked his results as satisfactory. The patient ends the call feeling reassured that there doesn’t seem to be anything wrong and that his symptoms will eventually resolve.

However, the symptoms worsen and the patient returns in four month’s time. When the GP checks the previous consultations, she realises that one of the requested results is not available within the record and sends the patient for re-testing. It is unclear why the result was not returned to the practice; however this failure could result in a delayed diagnosis for the patient which could result in a poorer prognosis and additional unnecessary suffering.

This scenario is not unusual. Other common errors relating to multiple results (see also page 14 of this issue) include clinicians ling the result without required action, or results for the same patient being seen by different clinicians leading to fragmented views of the patient’s overall condition.

To minimise risk consider:

• Training for non-clinical staff in understanding tests and results.
• Undertaking regular audits to assess the number of tests which are not returned – this can vary significantly by practice. This will allow you to make a judgement about the frequency of the problem and allocate resources to mitigate the risk.
• Implementing a system where all specimens taken are matched with the corresponding result received at the practice. These matching systems can allow receptionists to see clearly when there are any outstanding results – information which is useful to pass on to the patient and for prompting investigation into the reason for the delay or non-return of the result.
• Building continuity within clinical systems to reduce risk – and also increase efficiency. For example, when the clinician who requests the test also reviews the results, this can lead to better situational awareness and prevention of harm.

RISK 2: ACTIONING OF SIGNIFICANT RESULTS

The majority of results in general practice are work-flowed and viewed electronically. When a clinician is concerned about a result, they may direct a non-clinical member of staff to take action. Required actions can include contacting the patient to make an urgent or non-urgent follow-up appointment, asking the patient to collect a prescription for treatment, or informing a patient of the results and advising that they be rechecked after a period of time. There are multiple opportunities for error here.

Has the level of urgency been effectively communicated between clinician and non-clinical staff and is the message to be passed to the patient clearly understood? If not, this could result in the patient receiving inaccurate information or a receptionist being placed in the difficult position of feeling pressurised to interpret a result.

Does the patient attend for a follow-up appointment? If not, are DNA patients reviewed to check whether the practice has initiated contact? The fact that a patient has not attended for an appointment can be a ‘positive’ within a busy morning surgery – however if the record is not checked by a clinician, required actions may be missed. What happens to prescriptions connected to abnormal results which have been left for patient collection? If the patient decides not to attend and collect the prescription, can it be destroyed after a period of time without a cross-check for clinical need?

Such actions could constitute missed ‘flags’, alerting a clinician to non-compliant behaviours. Although patients have the right to refuse treatment, such decisions should be informed by a full discussion of the associated risks and consequences – and it is unlikely that this will have taken place at the initial consultation when tests were ordered or later when results and necessary actions were passed on by a non-clinical team member.

Another consideration is how the practice deals with hospital requests for follow-up in general practice? Depending on the nature of the patient’s condition and the clinical risk, it may be that the practice should diarise these actions for appropriate follow-up.

To minimise risk in the actioning of significant results consider:

• Reviewing the clarity of instructions given by the clinical teams to receptionists or other non-clinical staff – particularly those who are communicating directly with patients about results.
• Encouraging clinicians to take the time to review patients who DNA for consultations.
• Empowering non-clinical team members to check with clinicians when unsure of messages – or passing the patient back to a clinician when the patient requires further advice.
• Encouraging team members to document all contacts and attempts to contact patients, including messages or in- structions that have been passed. This ensures that there is an audit trail in place and that information is available to whomever next deals with that patient record.
• Incorporating the responsibility for recalls for repeat testing within existing call/recall roles.
• Returning uncollected prescriptions to the responsible GP for review before they are destroyed.

RISK 3: GIVING OUT RESULTS

Practices will feedback results to patients in a variety of ways. Many will task receptionists to provide results via telephone whilst some retain that responsibility within the clinical team. A few will still write to all patients with results.

There are benefits and risks associated with all these approaches. For example, a clinician providing results directly to patients over the phone will be able to have a comprehensive view of the results in the context of the consultation. In addition, they will be able to engage in discussion with the patient if they have questions about the results. But using clinical time in this way could reduce the availability of appointments within the practice, resulting in delays and complaints.

When a receptionist has been delegated responsibility to pass on results to patients, an important consideration concerns protected time. Multi-tasking, distractions and interruptions are a direct cause of human error. Does the receptionist know how to deal with questions of a clinical nature? Are they able to review whether any results are outstanding? What identity checks are carried out before giving out the result? Could a spouse or parent access results inappropriately – for example when a minor has been seen by a GP on their own?

To minimise risks consider:

• Whether the individuals tasked with providing results to patients, if non-clinical, are trained and competent to do so – and that they understand the risks.
• Asking clinicians to note any urgent flags about the confidentiality of the result as part of their actioning – e.g. ‘result to be given to patient only’ where the patient is a minor.

REVIEWING PROCESSES

To support patient safety, practice managers should review each step in their results handling systems and ensure that the practice has a written, shared protocol for managing results. In particular, this should underline the responsibilities of all individuals within the system, and include agreed minimum timescales and mechanisms for viewing and actioning results.

By working together to develop a results management system, clinicians and non-clinical staff can understand the risks within their system and their own important role in mitigating these risks.

Liz Price is the training and consultancy services manager at MDDUS