- Make sure you have appropriate protocols in place for the healthcare team.
- Communicate clearly with colleagues, patients and other parties involved in the patient's care.
- Keep careful documentation of management plans.
In GP practices
In general practice, delays in a patient's diagnosis can occur because a test is not ordered, or results have been mislaid.
The following steps can be taken to minimise risk:
- Maintain a safe tracker system for logging test results and patients requiring follow-up, so that they are not lost in the system. Include the patient and GP's names, details of tests requested, when results are due, when the patient's records have been updated and whether the patient has been informed. It can also be used for audit purposes.
- Consider allocating the task of regularly checking and updating the log to one person who can alert the relevant GP as required. The GP can then decide to remove the patient from the log, if no follow-up is needed, or to take further action.
- Put in place practice protocols for dealing with test results, or for administrative tasks such as dealing with messages to and from patients. Protocols can be useful in setting out the standard of care to be provided, and defining responsibilities within the team. They can also help in the event of a complaint or claim.
- Implement a manual or computerised system to list patients about whom you have particular concerns, and who you would like to attend for regular follow-up or review. Periodically check and annotate this list.
A middle-aged female patient visited her GP complaining of tiredness and lethargy. She was concerned that she may be depressed and was putting on weight, which she attributed to 'comfort eating'.
The GP took a careful history and examined the patient, discussing possible causes such as the menopause. The patient was finding both her work and her marriage difficult and was anxious to have some help or support.
The GP referred the patient to the practice counsellor, but was also keen to exclude possible physical factors and asked the patient to see the practice nurse for some blood tests. The patient agreed and a full blood count and thyroid function tests were sent to the lab. When the patient called the surgery for her results, the receptionist told her that the doctor had annotated the results to say they were normal.
Six months later, the patient returned to the surgery feeling worse than ever. She said that the counselling had been partially beneficial, but physically she was struggling and had gained even more weight.
When the GP reviewed the patient's earlier blood test results she saw that the thyroid function test result was missing from the records.
Further investigation revealed that this had not been returned. A repeat test was performed and hypothyroidism was diagnosed. Fortunately, the patient accepted a full explanation and apology from the surgery and did not make a complaint.
In the MDU's experience, complaints and claims frequently result from system failures, rather than solely clinical errors by individuals.
Potential problem areas include where:
- an in-patient has moved wards before the test results have been returned
- results are signed and entered in the 'results' part of the notes without action being taken
- a patient has moved from in-patient to out-patient care, but a clear management plan is not documented in the clinical records
- a patient has left hospital but the GP is not informed of the test results
- hospital discharge paperwork does not clearly specify what test results are outstanding and the GP is unaware of the details of the investigations that have been recommended
- there is no clear indication of whether the hospital doctors are handing over responsibility for patient follow-up to the GP or continuing to monitor the patient personally.
In a hospital environment where patients may be discharged or moved to other departments it's important that there is a way of ensuring test results are followed up and there is clear communication with hospital colleagues, the patients themselves and the patient's GP.
Careful documentation of management plans in the clinical records will also help to ensure that patients can be followed up even if the original clinician is not undertaking the continuing care.
It's worth considering these risk management points:
- Doctors who work in an acute admissions area should have a protocol so that abnormal test results and tests which are diagnostically important are followed up even if the patient has been transferred to another hospital.
- Patients' notes should clearly record what tests have been requested.
- If you run an outpatient clinic, consider implementing a manual or computerised system to track test results of patients you are particularly concerned about, or would like to attend for follow-up or review. Periodically check and annotate this list. Some trusts have implemented computer systems to enable doctors to do this.
- Make sure letters are sent promptly to patients' GPs when they have been discharged. Include information about what tests have been requested and whether any results are outstanding. Responsibilities for following up these results should be clear.
- If things go wrong and you discover a test has been 'lost in the system', take steps to inform the person in charge of the patient's care so that the appropriate treatment can be arranged immediately. The patient should be informed and offered an explanation and an apology.
An eighty-five year old patient with known chronic obstructive pulmonary disease was admitted to hospital from his nursing home with a purulent cough and shortness of breath. His chest X-ray was clear and his chest responded well to IV antibiotics and physiotherapy, so after a few days he was discharged with oral antibiotics and told to complete his course. Once home, the patient initially improved, but did not fully recover.
He had a low grade fever and the GP was called to review him. The GP had received a short handwritten discharge note from the hospital, but there were no details of the investigations performed or the results so he telephoned the consultant's secretary to check. It transpired that a sputum sample had been sent to the laboratory while the patient was on the ward but the result had not been received by the time the patient was discharged.
When the secretary checked the computerised result, it became clear that the patient's infection was only partially sensitive to the prescribed antibiotic. The GP was able to provide an alternative course and the patient recovered fully, but the hospital team logged the incident as an adverse event and investigated it.
This guidance was correct at publication 15/08/2018. It is intended as general guidance for members only. If you are a member and need specific advice relating to your own circumstances, please contact one of our advisers.