Effective Management of Test Results Improves Patient’s Safety

by John McKiggan

A major study conducted by the Canadian Medical Protective Association (CMPA) has identified ten key areas that can help improve patient safety.

Diagnostic testing is a critical part of modern medical care. Conducting appropriate tests in a timely fashion and reporting results of testing is key to ensuring appropriate diagnosis and treatment.

Miscommunication a Risk to Patients

In today’s health care system patients may be treated, and diagnostic tests ordered, by a variety of physicians, nurses, and other health care specialists. The risks associated with miscommunication or inadequate follow up increases as the number of care providers increases and as time pressures on medical professionals increase.

The CMPA reviewed legal claims over a four year period (between 2006 and 2010) where the communication of medical and diagnostic imaging tests were alleged to have contributed to a delayed diagnosis or misdiagnosis.

No Follow Up

Failure to follow up on test results or diagnostic imaging reports was the most frequent error identified during the review.

The CMPA identified a number of problems including:

1. No follow up;
2. A delay in follow up; or
3. Inadequate systems in place to ensure appropriate follow up.

Lack of Communication Can Be Deadly

For example in one case we represented the family of a man who died from sepsis after bowel surgery. Doctors determined that the patient was suffering from an infection after the surgery and prescribed antibiotics to combat the infection.

Lab tests showed the bacteria that was the source of the infection was resistant to the antibiotics that had been prescribed. In other words, the antibiotics were not effective.

The doctor claimed he wasn’t aware that the antibiotics were not working because the lab results had never been communicated to him.

The patient died and we filed a claim on behalf of his surviving wife and young children.

Doctor Responsible for Follow Up

In Canada the courts have consistently held that a physician who orders a particular diagnostic test is responsible for following up on the results of the test in a timely manner.

The doctor must be satisfied that appropriate systems are in place in the physician’s office, the hospital or the laboratory to ensure test results are communicated to the ordering doctor in a timely manner.

Communication with Patients

The communication system must also ensure that appropriate steps are taken to report test results to patients and arrange for a necessary follow up care.

Unusual Results are Important

Finally, the system must ensure that unusual or clinically significant results are followed up on in a timely manner.

Key Safety Recommendations

The CMPA report contains six key recommendations that could significantly improve patient safety.

1. Create A Culture Of Patient Safety : CMPA recommends all staff be encouraged to identify and follow up on diagnostic test results. The most preventable problem is one that staff is aware of but doesn’t tell anyone about.

2. K.I.S.S.: Systems should be as simple as possible. CMPA encourages the use of tracking systems and check lists. I’ve posted in the past about studies that have found that surgical checklists dramatically improve patient safety: Surgical Checklists Save Lives: Help Prevent Medical Malpractice Claims

3. Use Technology: CMPA recommends doctors adopt technology or software that automatically reminds doctors to follow up on test results and alerts them when there has been no response. Of course no system, computerized or otherwise, can be effective unless it is actually used.

4. Prioritize: CMPA recommends that test results be prioritized as:

1. Urgent;
2. Critical;
3. Action needed; and 4. Pending results.

5. Talk to Patients: Keeping patients actively engaged in their health care can improve their safety. If patients are told why they are receiving certain tests and how long they should have to reasonably wait for the results it helps patients understand the importance of the test results for their health care and encourages them to follow up with their doctor if they haven’t received the test results in a timely manner.

6. Don’t Be An Ostrich: Keeping your head in the sand and assuming”no news is good news” is dangerous. Assuming that “someone” will notify you if test results require follow up increases patient risk.


Want to Know More About Diagnostic Test Errors?

If you or a loved one have suffered injuries that you think may be due to medical malpractice you can buy a copy of my book: Health Scare: The Consumer’s Guide to Medical Malpractice Claims in Canada: Why 98% of Canadian Medical Malpractice Victims Never Receive a Penny in Compensation. on Amazon.com.

Or you can contact me through this blog or by calling toll free in Atlantic Canada 1-888-647-7201 and we will send you a copy, at no charge, anywhere in the Maritimes.

Read Health Scare: The Consumers Guide to Medical Malpractice Claims and learn the answers to these questions:

•What is a medical malpractice case?
•What do I need to prove to win my case?
•What is the Standard of Care and why is it important?
•Top 10 reasons medical malpractice victims never receive compensation.
•How do I find a qualified medical malpractice lawyer?

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