Policies, procedures, and processes are some of the tools most commonly used by risk managers, and nowhere are they more important than in avoiding claims related to delays in diagnosis.
Having the proper processes and procedures in place can greatly reduce the chance of a diagnosis being missed or delayed, says Ann Whitehead, RN, JD, vice president of risk management and patient safety at the Cooperative of American Physicians (CAP), a malpractice insurance provider in Los Angeles.
“A physician’s failure to diagnose in a timely manner tops the chart as the most common allegation in medical professional liability lawsuits,” she says. “This is why it is very important for every physician, clinic, or hospital to establish a consistent process for tracking results.” Whitehead suggests focusing on these key areas to strengthen the diagnosis monitoring process:
- Clear communication: Devise a system that notifies every patient of every result. Never allow clinicians to use the “no news is good news” policy, in which the patient is told he or she will be contacted only if the test result is problematic.
- Notification: Establish a simple, standardized system for notifying patients of normal and abnormal test results, and document that communication process clearly. Every attempt to contact the patient should be documented in the record.
- Legible notes on lab sheets: For normal or non-urgent abnormal results, physicians should initial, date, and provide instruction for the patient follow-up on the actual laboratory result sheet.
- Immediate action on abnormal results: All urgent abnormal results should be immediately directed to, and followed-up by, the physician. These reports also should be dated and initialed by the physician or an advanced practice professional.
- Empower patients: Empower patients to serve as a double check system. Patients should be educated about what tests are being ordered, the purpose of the test, and when and how the results will be relayed. Give them a specific timeframe to expect the results, and direct them to call the office if they haven’t received their results.