Malpractice Action Based on Overlooked Actionable Test Results

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A recent article in Medscape, “Malpractice Case: Are You Sure the Patient Received the Test Results” discusses the complexity of large medical practices and the reality that in todays specialized environment, patients see multiple providers.  The article makes the very valid point that this situation leads to the potential for results not being communicated to both the patient and all practitioners treating the patient.


This can be especially problematic when patients miss appointments at which results normally would be discussed and there is not an aggressive attempt to alert the patient to problematic results.  The article made three key points:

1) Any delay in giving patients results increases the chances that the patient will not get the information

2) A fail safe plan is needed to alert the patient of any test results

3) Office staff members should keep track of when they call patients, how often they called and whether they actually spoke with the patient

These are all very valid points and the article, which discusses a case of non-communicated imaging results, is well worth reading and sharing with your staff:

An area the article does not mention specifically, but has long been of concern to me are results of patient testing performed at reference laboratories.  Ideally you need the reference laboratory ordering and reporting interfaced to your electronic records so that you have evidence of having ordered a given test, and are alerted when the results are returned to you.  You should have a written reference laboratory procedure which includes the requirement that a report will be generated by your practice on a regular basis to determine if there are any unreported results from the reference laboratory.  In addition, on at least an annual basis or when upgrades are made, it is essential to check the accuracy of any interfaces you are using.

If you are working with paper ordering and/or reporting and a non-interfaced system, it is essential that you have a written procedure in place to monitor the receipt of reports, indicate their placement in the medical record and the alerting of the ordering practitioner of the availability of the results.  If results are scanned into the medical record, it is ideal to have them reside in the location where all other laboratory results are maintained.  

Regardless of system used with the reference laboratory, be it an electronic interface or paper, you should have as part of your procedure the requirement for documentation in the medical record of how and when the patient was informed of the results.


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About the author

Dr. John Daly

John T. Daly, M.D. is Chief Medical Officer of COLA. Dr. Daly received his MD degree at Weill Cornell University Medical College, performed his internship and residency in Anatomic and Clinical pathology at Duke University Medical Center and a residency in Forensic Pathology at the Office of the Chief Medical Examiner in Chapel Hill, N.C. He is board certified in anatomic, clinical and forensic pathology. Through the course of his career, Dr. Daly has had extensive experience directing and advising laboratories of all sizes including physician office practices, Federal Health Clinics, surgical centers, Community Hospitals and the integrated academic health system clinical laboratories of Duke Medicine. He retired as Director of Laboratories of Duke Medicine, and continues his affiliation as a member of the emeritus staff. He then joined the accreditation organization, COLA, as the Chief Medical Officer. In this role he continues to provide guidance that helps labs improve safety in labs, standardize and streamline operations while achieving CLIA compliance.


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