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.
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