Nihal D’Cruz, Underwriting and Risk Education Manager at MIGA, shows us the critical link between practice systems and clinical outcomes.
Today’s medical practice is a busy, pulsating entity, regularly working overtime pumping out patients. On most days patients come and go without incident, but when something does go wrong it’s often due to unhealthy practice systems and procedures.
Doctors know the benefits of promoting preventative medicine to their patients. It is equally as important that they embrace this message.
A leading case on failed systems concerned a doctor who didn’t see critical pathology test results. They’d been faxed to the practice but misplaced and there was no system to warn the doctor that he didn’t have them. The patient cancelled an appointment so it wasn’t until some considerable time later when she made a new appointment that he realised the oversight. By then her condition was terminal.
In a recent notification to MIGA, a Urologist received a concerning abnormal PSA result. The result was filed but because the patient failed to attend a review appointment it was overlooked for eight months.
In another notification, a Radiologist was unable to locate a breast lump to undertake a fine needle aspiration so she sent the patient to a Sonographer for an ultrasound. There was no internal system for following up the report on this procedure. The result was misplaced, the FNA was not done, a report was not generated and the cancer was not diagnosed.
Poor communication protocols between medical providers, be that GPs and Specialists, Surgeons and Anaesthetists, locums and their employers, or colleagues within a medical team, can also contribute to adverse events or outcomes.
Today’s doctors need to consider the health of their practice not just the health of their patients. It’s also important to provide leadership and support to the practice team to ensure everyone is working effectively and the team culture is one of continuous review and improvement.
There are lots of examples where unhealthy systems or system malfunctions can impact on the healthy delivery of good patient care. It’s always a good time after an adverse incident to evaluate whether your systems and procedures need some medicinal attention. In addition, maintaining a healthy practice also requires more regular screening, examination and review.
Case study – unexpected results
On 23 December, Susan was referred by her GP for a 19 week morphology scan. She attended for the scan on 28 December.
The Radiologist prepared the report the following day noting a number of foetal abnormalities. The Radiologist recommended a follow-up foetal MRI.
The report was faxed and mailed to the GP on 29 December. That same day, Susan collected the scans from the radiology centre but noted that the report was not included. She presumed that the GP would contact her if anything was wrong.
In early February she consulted a different GP in the same practice and was advised of the results of the scan. An MRI was done urgently and confirmed severe abnormalities.
Proceedings were issued against the GP, the general practice entity, the Radiologist and the Radiology practice. The claim for damages was based on the delay in the communication of the results of the abnormal morphology scan and the failure of the GP to follow up the results. "
Communicating unexpected results – duty of care
MIGA obtained legal opinion that concluded, in particular, that there was a significant risk that a court would regard the Radiologist's failure to attempt to verbally contact or alert the GP to the urgency of the report as a breach of his duty of care.
The Royal Australian and New Zealand College of Radiologists (RANZCR) and the Royal College of Pathologists of Australasia (RCPA) have similar expectations; that those preparing the report have obligations to report unusual, urgent or significant unexpected findings to the referrer in a timely manner. The timeliness is determined by the severity of the finding in the clinical context.
Communication breakdowns may have an outcome of a referring practitioner not acting on a test result. In the case of significant abnormal findings it would have been best practice for the Radiologist to contact the GP by phone. In this particular case, the time of year may also need to be considered as a factor in the delay in the patient returning to the GP for follow-up.
Systems and procedures
In this case the GP's defence was that he had not received the report and that the usual procedures of the practice had not been followed to ensure that the result was provided to him.
There are a few things to consider when a new system or procedure is put in place or if you have a system that hasn't been reviewed for some time:
- Ensure that any new system, or changes to existing systems, are communicated to all staff
- Is the system or procedure working as it was intended? Consider an audit and address any gaps the audit reveals
- Provide training and updates for practice staff and health professionals
- The practice manual is a great tool for staff to use – is it up to date?
No matter what system you use, be sure that it is sufficiently vigorous to alert the practice to the issues that require follow- up. This includes not only attendance for tests, investigations or other healthcare appointments, but also how to manage unexpected significant findings.
A common query
At MIGA, we often get asked the question, “When I receive a result that is abnormal or ‘clinically significant’ to what lengths should I go to recall a patient and how do I make sure that this happens?”.
Our advice is that any result that is abnormal or ‘clinically significant’ should be followed up and the patient recalled for a consultation. However, ‘clinically significant’ results do not necessarily mean ‘abnormal’ results. It is a judgement made by you, in the context of the patient’s health care that the patient needs to be seen for further management.
To ensure that a recall system is as failsafe as possible, the practice should consider a team approach when coordinating the recall. However, it is the responsibility of the practitioner who ordered the test to see that the recall and follow up is actioned. Reminders and recalls are two very different aspects of care.
Reminders apply to routine tests or investigations where there is no past history of any problems and, as such, it is up to the patient to attend for a consultation if they choose. The obligation on the practitioner for a recall when results are abnormal is quite different.
Reminders are often sent by a practice as a matter of course. They are a courteous reminder that the patient is due, for example, for a PAP test. Usually a letter to the patient’s address is sufficient where there has been no problem in the past. However, for this to work effectively practices need to ensure that patient contact details are kept up-to-date. This is usually done through practice staff confirming contact details remain correct before each consultation with you.
In circumstances that require a recall such as an abnormal result or something that is ‘clinically significant’, the obligation on the doctor and the practice is greater. We recommend the following steps are taken when endeavouring to recall a patient:
- Up to three calls to the patient’s nominated phone number(s)
- A letter sent via normal post
- A registered letter.
All of the attempts should be documented clearly in the medical record, including the time of the phone call and any message that was left with another person, on voicemail or a home answering machine.
Keep in mind issues of privacy if you are leaving messages of any form. Keep a copy of any returned letters and envelopes in the medical record.
If your attempts to contact the patient are ultimately unsuccessful, you should contact MIGA to discuss next steps. If you are able to speak to the patient, you should avoid disclosing any ‘bad news’ about results over the telephone. This needs to be done in the consultation with the patient, allowing you to counsel the patient about the results and assess the need for emotional support.
These steps are a guide and, if followed, should provide you with a good defence if allegations arise of failing to recall a patient.
Take away message
The importance of a reliable recall and follow up system cannot be underestimated.
Practices should take some time to review their practice systems to ensure that they are as failsafe as possible and that staff understand the importance of following the process.
We have developed a Fact Sheet on this topic which can be accessed via the Risk Resources library on our website or you can contact our office for a copy.
Insurance policies available through MIGA are issued by Medical Insurance Australia Pty Ltd. MIGA has not taken into account your personal objectives or situation. Before you make any decisions about our policies, please read our Product Disclosure Statement and Policy Wording and consider your own needs. Call MIGA for a copy on 1800 777 156 or visit our website at www.miga.com.au. The information contained in this document is of a general nature only and does not purport to take into account, or be relevant to your personal circumstances. This information is not intended to be nor should it be relied upon as a legal or any other type of professional advice.
Risk management resources
MIGA has helpful risk management resources specific to this topic which are available to clients, or by contacting their Risk Management team on 1800 777 156. In addition to their industry-leading risk management education, MIGA offers superior cover and expert medico-legal support 24/7. If you are not insured with MIGA, give them a call to see if they can offer you more value and better protection. Or please contact us if you would like an introduction to Nihal D’Cruz.