As the medical world has embraced electronic records and methods of communication, the volume of electronically received test results and other communications requiring actions has become large, even onerous. Every such test result or communication requires careful consideration – even a normal result can sometimes be significant in certain clinical contexts.
In general practice, a GP working 8/10ths might expect to review 20,000 test results and communications each year. Over a 30-year period that is 600,000 results and communications. The risk of an oversight or error in managing these is real and should be a concern for all practitioners.
Many of these have simply been copied to the GP by a third party, but still require careful attention. A month ago, I received a very abnormal FBC result, copied from the local ED, which required hematology referral and intervention. This had not been acted upon by the ED, leaving me with, at best, shared responsibility.
Over time various strategies have been employed to mitigate this risk, including software systems and practice processes. However, despite the continuing evolution of these processes, there is no real foolproof method. A significant risk remains, and all of us need to be vigilant in this regard.
For example, Post-It Notes and pop-up alerts within the software system can lead to fatigue, not unlike alarm fatigue. Other methods employed include setting recalls, not filing results (so they remain active) and setting a task for oneself.
Tools such as Manage My Health which provides patients with access to results and which facilitates communication with patients can be helpful. While this may allow for some risk sharing with the patient, they do need to be educated to look for results, and even enquire about them. While this sharing of results and communications does empower patients, it is not a solution.
Despite our best-efforts errors and omissions do occur, and the important thing is to notify the affected patient, when it is recognised and take the appropriate clinical action. This should be followed by an investigation to determine how the error occurred and what can be done to prevent this happening. This investigation should be recorded.
Medicus recommends that from time to time you should reflect on how you are managing your results and mitigating the risk, both at an individual and practice level.
I encourage you to look at the HDC link below for advice and discussions on how to mitigate this risk. I have attached two recent case studies to highlight this issue.
A case of not notifying results …
In case 00HDC07636 (8 March 2001), a GP was found in breach of the Code for failing to inform a patient of her test results. An Asian woman presenting in her 14th week of her second pregnancy had an abnormal result for syphilis serology (negative TPHA and positive RPR). The GP had intended to discuss the results with her at the next antenatal visit (scheduled for 20 weeks) and arrange further testing, but she did not attend. At 27 weeks she delivered a stillborn fetus, which had died from chronic fetal infection. The woman was found to have active syphilis infection.
What if the Medical Centre never receives the results of an investigation?
In case 99HDC11494 (7 May 2001), a woman with a history of fibrocystic disease and recurrent breast cysts presented with a slightly painful breast mass that could not be aspirated.
She was referred by her GP for mammography and an ultrasound scan. The report was expected within three weeks. Nine weeks after the mammogram, the patient contacted the medical centre to enquire about her results and was reassured by her GP that she would be contacted if there was something wrong. The practice nurse then chased up the report.
A month later, having still heard nothing, the patient called the Medical Centre again - 13 weeks after the mammogram. The practice nurse contacted the testing facility that day, obtained the results (which were abnormal), and notified the patient. In a report in this case, an expert stated: "In my view any test ordered where the doctor has reason to suspect a diagnosis of cancer requires a proactive follow-up by the referring doctor." It was recommended that the Medical Centre implement a bring-up system for follow-up of overdue results in appropriate clinical areas. The ruling prompted a lot of discussion in the profession, and led the RNZCGP to develop its guidance paper "Managing Patient Test Results - Minimising Error" (updated in 2005).
This is and will remain an area of risk for all those health practitioners ordering tests. The matter requires specific attention, with systems being in place to mitigate the risk.
Read the full guidance here: https://www.rnzcgp.org.nz/gpdocs/New-website/Advocacy/PB6-2016-Apr-Managing-patient-test-results.pdf
Andrew Dunn, GP
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