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Eight ways to improve management of test results at your practice

Dr Bryony Hooper, medicolegal adviser at MPS, looks at some of the issues GPs face surrounding test results, and offers tips on how to manage these risks for the benefit of the patient and the practice

One day in your afternoon surgery a patient comes for their annual medication review. He mentions that he never heard back about the result of that mole you removed four months ago and sent to the lab. To reassure the patient you look up the result, and to your horror find that the mole was a malignant melanoma. Such scenarios may seem unlikely, but they do occur. MPS data collected from 121 Clinical Risk Self Assessments (CRSAs) of general practices during 2012 identified the handling of test results as one of the top ten risks.1

Making a diagnosis or deciding whether to refer a patient is often dependent on investigations done in primary care. Ensuring investigations are done safely and efficiently is a complicated, multidisciplinary process, and yet some practices spend little time reviewing their systems.

Electronic systems have changed the way we order and receive results, and in some cases how we inform our patients. Systems which may have worked well for paper results may not adapt well and need to be revised. Having robust processes in place to deal with test results can greatly reduce the risk of errors or problems occurring, and help you to prevent avoidable harm to your patients.

In one of the case studies MPS worked on, a 25-year-old man was found by his GP to be hypertensive. Investigations were done including renal function tests which showed a mildly elevated creatinine. He was initially referred to the cardiology department who advised on treatment for his hypertension and repeated his blood tests. He then returned to his general practice where indapamide and perindopril were started by the GP. Although the patient attended intermittently for BP measurement and prescriptions, his renal function was not tested again until one year later, when his creatinine was found to be elevated at 205µmol/l and his eGFR reduced at 37ml/min. This result was initialled by the nurse. He attended a month later for a further BP check, and was advised by the nurse to have further blood tests. These tests showed a deterioration, with a creatinine of 254µmol/l and an eGFR of 30. At this point the nurse spoke to the GP, who made a referral to the nephrology department. The patient subsequently underwent a renal transplant.

The practice accepted that they had failed to arrange for the appropriate tests to be done regularly, and to ensure that the results were reviewed by an appropriate clinician. They have since altered their procedures to ensure that similar patients would be recalled regularly for renal function tests, and the result reviewed by a doctor.  

Here are some tips on how to deal with test results effectively and efficiently, to ensure that you’re doing your best for your patients.

1 Create a checking system to ensure you don’t miss a test

Try to ensure you have a system which allows you to record, where possible, when a test has been completed. This may not be possible for some, such as x-rays, but for tests done within general practice such as blood or urine samples, it should be a straightforward matter of good record keeping. For tests done outside the practice, consider whether you should keep a log of the request, which can be checked against results received, where feasible.   

2 Minimise lost results

Most practices should have a system in place to minimise lost results but if not Identify who should take responsibility for ensuring test results arrive, and how. In many practices the nurse or Health Care Assistant will undertake a regular review to check that results have been received for all the tests sent from the practice.

GPs also have a role in checking that results have been received when the patient is reviewed, or new prescriptions ordered. Lost results are not uncommon, even with computerised systems, and may result in false reassurance that all is well.

3 Identify the next steps

When the results have been received, they need to be seen by the appropriate clinician. Check three things:

- Will they automatically appear on the relevant clinician’s screen, or do they need to be ‘pulled down’ first?

- As in our second case study, will the clinician have all the necessary information available to ensure they act appropriately on the result?

- How do other members of the team know that the result has already been seen and acted on? 

Some results may need urgent action, such as a high potassium level, and your system should clarify how such action will be taken, and whose responsibility it is to ensure that the patient is advised of action which needs to be taken.  Ensuring that the right person sees the result, and the action requested is acted upon by members of the team, is essential if the test is going to benefit the patient

4 Make sure everyone knows your system, whatever you use

Some studies have shown that combining both paper and electronic record keeping can lead to high rates of missed test results, and complete electronic systems may be somewhat safer.2 However the processes involved in ordering, arranging, reviewing and acting on results are multifaceted and complicated, and whatever system is used it needs to be flexible to the needs of your practice and patients. If record keeping is incomplete then the system cannot work well. Practices should ensure that they have a clear system for recording which tests have been done, what results have been received, and what action has been taken as a result.

5 Audit your recall system

When determining what tests are required, some tests are easy to schedule - a patient may need monitoring of their cholesterol, or take lithium and need regular thyroid function tests. Each practice will need to be able to identify those patients needing regular investigations, or follow up to a previous test. Electronic systems usually do this effectively but it is essential the process as a whole is audited regularly to ensure the right patients are receiving appropriate test requests. You also need to be able to identify those who have not complied with the request to undergo further investigation.

6 Check every patient receives their results

This is a vital area and one which quite frequently fails. Some practices tell patients that they will let them know if there is a problem or further action is needed. This misses a potential opportunity to ask patients to find out the results themselves – although this should not be relied on as the sole means of informing the patient, asking them to contact the practice can provide an additional safeguard and helps to avoid patients assuming that all is well because they have not heard from the practice. Clarify with the patient whether the practice will contact them, or whether you expect the patient to also take steps themselves to find out the result. Make sure you have a system for identifying results which have not yet been communicated to the patient.

7 Assume responsibility for hospital test results

Communication with secondary care is an area that can be fraught with difficulties and this is no less the case for results. Patients may have a test done in out-patients or the A&E department and the result is sent to the practice.

In general, the safest default position is to assume that responsibility lies with general practice unless you have clear evidence that those ordering the test intend to follow it up.

8 Keep results confidential

In the drive to ensure that results are dealt with efficiently, and acted on when necessary, it can be easy to be casual about patient confidentiality. Results:

- should never be given to patients in an area where other patients can overhear, including by phone from the practice reception area;

- if given out by phone, should only be told to the patient themselves, unless it has been agreed with the patient that the result will be given to someone else;

if given out by text or email, must be given out only with patient consent to do this. Ensure practice staff are aware of the possibilities of others seeing such information unintentionally.

Dr Bryony Hooper is an MLA at the Medical Protection Society.

References

1 The data is from 121 Clinical Risk Self Assessments (CRSAs) in the UK and Ireland, undertaken from January 2012 – December 2012. CRSAs are an MPS service, which has been developed to assist practices in identifying their specific risks.

2 Callen J, Georgiou A, Li J, Westbrook JI .The safety implications of missed test results for hospitalised patients: a systematic review. BMJ Qual Saf Health Care. 2011 February; 20(2): 194–199. doi:  10.1136/bmjqs.2010.044339

Readers' comments (8)

  • I do not agree with 7. As per GMC guidance, results are the responsibility of the person ordering them, so GP's can not and should take responsibility of any test not requested by them. please check these facts. otherwise bone marrows and MRI results will all come our way to be acted on and this is unsafe for the patient and a medicolegal nightmare for the GP.

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  • line 3 above should read
    should NOT take responsibility for any test...

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  • I agree point 7 is complete non-sense and reduces the credibility of what would have been an otherwise useful article.
    Point 6 is extremely difficult to implement given the sheer volume of tests that we do nowadays and would require immense time and money resource to ensure results received by every patient.
    as a 2nd best alternative-- perhaps not as medico-legally defensible-- with every test request we give a set of verbal and written instructions to the patient that they must contact the surgery and ensure that they know their results and they must not assume that the surgery will only contact them if there is something abnormal--although we obviously do contact patients when results are abnormal and need to be acted on

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  • 40+ consultations + 150 other contacts in a day [letters, results, acute + repeat scripts, phone calls, referrals ] ;
    somedays over 200+ contacts = what is safe ?
    Candour - our working conditions are dangerous -
    When does workload impinge on patient safety?
    Who decides safety in an imposed contract ? Is it time to define safe workloads ?

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  • The general principles have not changed over the years: those requesting the test is responsible for appropriate follow-up, but I must agree that sheer volume of workload makes the process unsafe, as does increased part-time/portfolio working where other practice members often need to action the results of an absent colleague. Whilst we always advise patients to check up on their results, it would be a productive step forward for the NHS as a whole if we could set a standard for safer result-sharing. Receptionists can only relay a certain amount of information as non-clinical staff, and appointments are so scarce we cannot see all to advise. Is it practical or reasonable now to shift the responsibility for result collection to the patient (or their carer)? The principle of no news being good news is no longer safe with present imposed workloads.

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  • David Bush

    This is a very interesting thread - about safety responsibilities in a system where the workload is imposed. I would like to see a test case where a GP who has made a mistake or omission uses as his defence the impossible workload effectively imposed by the Dept Health by the system we work within. Perhaps the Defence organisations might seriously consider this course of action.

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  • Do NOT assume responsibility for hospital tests. This is the way our work increases without additional resource to support it. The GMC is quite clear on this matter. The instigator of the test is responsible for dealing with the result. Just copying in the GP is not a transfer of care. I frequently just fax these otherwise anonymous results back to the A&E, the pre operative clinic, out patient etc etc with a note asking the consultant what have they done about these abnormal test results they have discovered as a result of their investigations.

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  • I think it is safe to tell patients to contact the practice for the results. If the tests are done as part of investigations for a problem for which they have seen a GP, the latter can make it easier by saying the results will be discussed at the follow-up appointment. Any other results which are abnormal, deserve a telephone consultation if they are not due to see the GP soon.

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