CAP continues to see claims as a result of lost and/or misplaced test results. Unfortunately, when this occurs, the impact on patient outcomes can be as severe as a missed cancer diagnosis. A recent review in the Journal of General Internal Medicine1 reported that few ambulatory settings have policies or guidelines for test follow-up.
To prevent patient harm due to misplaced lab or radiology reports, CAP Risk Management & Patient Safety recommends physicians develop the following protocols for their practices:
- Do not tell patients "no news is good news." Giving this advice, a lost report may not be noticed until a serious disease has progressed.
- Create a "tickler file" for outgoing lab and radiology requests that notes an expected date or week for return. This may be in an electronic system, a logbook, or keeping the medical record in a separate area filed by expected return date of the report.
- Check incoming lab/radiology requests against those expected. Using this practice, missing reports are immediately identified.
- Assign specific staff to the above responsibilities so it is not overlooked.
- All laboratory and radiology reports should be reviewed by the physician or an advanced practice professional such as a nurse practitioner or a physician assistant.
- Notify the patient of the results and any needed action.Responsibility for this task also should be assigned to assure it is done. If the patient is given any responsibility for follow-up, document that in the medical record.
The above steps help protect patients while decreasing the physician's risk of liability.
1 Failure to Follow-up Test Results for Ambulatory Patients. Journal of General Internal Medicine, 2012 October; 27(10): 1334-1348
If you have questions about this article, please contact us. This information should not be considered legal advice applicable to a specific situation. Legal guidance for individual matters should be obtained from a retained attorney.