Diane Baylis, clinical risk and education manager at Medical Protection, looks at the role of contributory factors in test result errors
A 22-year-old lady attended a surgery and was seen by the advanced nurse practitioner (ANP). The patient complained of thirst and weight loss; she was concerned as she had a family history of diabetes. The ANP ordered bloods for fasting glucose.
Two days later, the ANP reviewed the fasting glucose result and noted it to be 16.8mmols. The ANP documented that it was abnormal and sent an electronic message to the administration staff to recall the patient.
The receptionist telephoned the patient to inform her that the ANP needed to discuss her test results and made an appointment for the patient to be seen in six days’ time. An appointment text reminder was sent.
The patient failed to attend the appointment. The ANP telephoned the patient and it appeared that the patient had attended the wrong surgery (as the practice had two sites). The ANP advised the patient that the blood test needed to be repeated, followed by a consultation with the GP.
The blood test was repeated and the result was significantly higher than the first test. Thus, the GP decided to make a home visit. However, the practice did not hold an up-to-date address of the patient – the GP went to the address of the patient’s parents instead and had missed the patient visit.
The patient attended a walk-in centre the following day and was admitted into hospital.
Key contributory factors in this case
Individual
- The ANP did not recognise the urgency of the raised glucose and did not ensure that the patient was given an urgent appointment with the GP.
Patient
- The patient had not informed the practice of a change in her address.
- The patient attended the wrong site for her appointment.
Organisational
- The practice has two sites. This may have confused the patient. The practice did not have systems to ensure that patient demographic details are kept up-to-date. This could easily be done if the patients are being asked about their contact details at various points of contact such as at the reception, during the consultation and through communication materials like a leaflet.
This scenario is fictional but based on real Medical Protection cases.
Errors in managing test results: contributory factors
We looked at 50 randomly selected claims from general practices over a three-year period – January 2014 to December 2016 – and found evidence of suboptimal management of test results.
All 50 cases, in addition to system errors, had contributory factors, identified by using a framework for patient safety incident investigation known as the “Yorkshire Contributory Factors Framework (YCFF)”. The framework uses the following parameters:
- External factors
- Organisational factors
- Local working conditions
- Patient factors
- Team factors
- Task characteristics
- Individual factors.
How they measure up: the role of contributory factors in cases
Individual factors
- Inexperienced practice nurse who failed to undertake the blood tests requested by the GP, and misinformed the patient that their test results were normal.
- GP overlooked the abnormal test result by relying solely on the computer system.
- Locum GP may lack the knowledge of that particular practice’s system.
Task characteristic factors
- Data input error in computer system.
- Incorrectly picking the wrong dropdown box on the computer software. Thus, the patient was informed that their test was normal when they should have been directed to consult their GP.
- Complete reliance on the computer software to highlight abnormal results.
- Poor documentation.
Team factors
- Inappropriate task delegation.
Patient factors
- Patient did not fully understand the process due to having learning difficulties.
- Patient did not follow up with their test results.
- Patient with multiple medical conditions.
- Patient who frequently failed to attend appointments.
Local working conditions
- Unclear responsibilities with regards to review or follow-up of test results.
- Lack of system to ensure test results are reviewed by the requesting clinician.
- Lack of continuity in patient care resulting in confusion over whose responsibility to ensure patient follow-up.
Organisational factors
- Lack of a consistent system to announce urgent action.
- Lack of practice systems for reviews or follow-ups; no annual recall system.
- Practice reliance on the patient to contact the practice for test results.
- Practice process of allocating the senior GP to review all the test results of patients whom they have not personally seen.
- No test result audit.
External factors
- Ambiguity about who was responsible for ordering a test, when the patient was under the care of both GP and the hospital.
- Ambiguity in referral guidelines for a specific condition.
- No clear system for sharing test results between primary and secondary care.
- Test results were sent to the wrong practice, in a shared building, perhaps due to similar-named GP.
Summary
There are many benefits from increasing reliability of the test results management system. Safe and reliable systems help to:
- Achieve consistent outcomes despite different individuals involved
- Maintain standards
- Reduce the likelihood and impact of individual error.
Inadequate or poor communication of test results to referrers and inadequate arrangements for a follow-up after the test results are nationally-acknowledged patient safety issues. Better communication between healthcare professionals and patients is vital to improve the test result system, thereby improving patient safety outcomes.
Medical Protection’s Test Result 360, a user-friendly online tool, helps practices to develop a robust test result system. The tool takes about 15 minutes to complete, and it will provide a useful online audit of your test result system. To register, email
[email protected]
Read part 1 of learning from negligence claims to read our analysis of the system interactions, and how they can cause adverse events in test result management.