The TAPS study found that errors in the process of providing health care were reported by general practitioners more than twice as often as deficiencies in a clinician's knowledge or skills. Approximately 20% of these process error events concerned investigations. In addition, some reported events that related to investigations included filing system and recall errors, which accounted for a further 10% of reported error events.2 page(s

Bridges-Webb, Charles

Kidd, Michael Richard

Makeham, Meredith A B

Makeham, Meredith A. B

Kidd, Michael R

Macquarie University ResearchOnline

Lessons from the TAPS study : managing investigation results - is your practice system safe?

Flinders Academic Commons

Archived at the Flinders Academic Commons:  http://dspace.flinders.edu.au/dspace/  This is the publisher’s copyrighted version of this article.  The original can be found at: http://www.racgp.org.au/afp/200808/200808makeham.pdf © 2008 Australian Family Physician www.afp.org.au Copyright to Australian Family Physician. Reproduced with permission. Permission to reproduce must be sought from the publisher, The Royal Australian College of General Practitioners.  clinical practice  the tapS study found that errors in the process of providing health care were reported by general practitioners more than twice as often as deficiencies in a clinician’s knowledge or skills. approximately 20% of these process error events concerned investigations. in addition, some reported events that related to investigations included filing system and recall errors, which accounted for a further 10% of reported error events.errors in the management of investigation resultsThe TAPS study collected 648 reports from a representative sample of New South Wales GPs.1 There were several areas described where processes around investigations had failed.2 The most problematic area in terms of potential for harm was related to the management of investigation reports. This occurred when investigation reports were filed before the GP had seen them, GPs missed an abnormal result (for example on a second page of a report), and abnormal results were noted by the GP but then not followed up.  The Australian Critical Incident Study of the mid 1990s identified four stages where incidents relating to tests and investigations were commonly found to have occurred: arranging the test, the testing process, communication of results to GPs, and follow up of results with the patient.3 It was found that over half of the incidents associated with investigations could probably have been prevented through more efficient systems for maintaining and passing on test results, and recalling patients for follow up.Michael r Kidd MBBS, MD, FRACGP, is Professor and Head, Discipline of General Practice, The University of Sydney, New South Wales.charles Bridges-Webb aOMBBS, MM, MD, FRACGP, is Director, The Royal Australian College of General Practitioners NSW Projects, Research and Evaluation Unit, Sydney, New South Wales.Meredith a B Makeham BMed(Hons), MPH(Hons), PhD, FRACGP, is Clinical Lecturer, Discipline of General Practice, The University of Sydney, New South Wales. meredith@gp.med.usyd.edu.aulessons from the tapS studyManaging investigation results – is your practice system safe?clinical lessonGeneral practices need systems in place to ensure that investigation results are received, checked, communicated to patients and appropriately acted upon. Clinicians in any setting must take responsibility for ensuring that all results are checked and that action has been taken regarding all investigations that they have performed or requested.case studyA woman, 72 years of age, presented to a hospital emergency department with a history of abdominal bloating, reflux and discomfort over many months. Nine months previously she had been referred by her GP to a hospital outpatient clinic for a gastroscopy. On the day of the procedure, the patient was told by a hospital registrar that all appeared normal, and she had ceased her proton pump inhibitor medication. The gastroscopy report was sent to the GP, and said: ‘normal, biopsy sent’. When the patient's hospital notes were reviewed 9 months later in the emergency department, the histopathology report suggested that there was mild gastritis with the presence of Helicobacter pylori. The GP had not seen a copy of the histopathology report and the patient had not been notified of the abnormal result by anyone at the hospital.The Threats to Australian Patient Safety (TAPS) study collected 648 anonymous reports about threats to patient safety from a representative random sample of Australian general practitioners. These contained any events the GPs felt should not have happened, and would not want to happen again, regardless of who was at fault or the outcome of the event. This series of articles presents clinical lessons resulting from the TAPS study.commentThis report illustrates the need for systems that ensure that all abnormal investigations are followed up. The abnormal histopathology findings were not communicated to either the patient or the GP by the hospital clinician involved in this case. A flag on the GP’s file that the biopsy results were outstanding may have prompted the GP to chase up this result.reprinted from auStralian FaMily phySician Vol. 37, No. 8, August 2008  625lessons from the tapS study – managing investigation results – is your practice system safe?clinical practice In terms of medicolegal risk, up to 50% of medical negligence claims arising in general practice result from a failure to diagnose a patient’s condition, and these claims commonly arise from a failure in the practice’s test result management system.4 The case study presented also highlights a failure in hospital communication with general practice, which was a common finding in the TAPS study. This type of error accounted for close to 10% of all process error events reported.2errors in investigation processes found in the tapS study •	Incorrect	patient	 identification,	eg.	 treating	a	patient’s	urinary	 tract	infection based on another patient’s investigation results that had been incorrectly filed•	Errors	 in	 the	process	of	 requesting	 investigations,	 eg.	 ordering	an	investigation for a patient and accidentally putting the details of another patient on the form•	Incorrect	tubes	accidentally	used	when	blood	samples	were	collected	•	Delays	in	receiving	abnormal	pathology	results	•	Reports	being	filed	without	the	GP	having	seen	them•	GPs	not	noticing	that	there	was	a	second	page	attached	to	a	pathology	report and missing the report of abnormal pathology.Conflict of interest: none declared.acknowledgementThe TAPS study was funded by a NHMRC PHC project grant. Meredith Makeham was a NHMRC scholar and received additional support under the Researcher Development Program, PHC RED Strategy, funded by the Commonwealth Department of Health and Ageing.references1. Makeham MA, Kidd MR, Saltman DC, et al. The Threats to Australian Patient Safety (TAPS) study: incidence of reported errors in general practice. Med J Aust 2006;185:95–8.2. Makeham MA, Stromer S, Bridges-Webb C, et al. Patient safety events reported in General Practice: A taxonomy. Qual Saf Health Care 2008;17:53–7.3. Bhasale A, Norton KJ, Britt H. Tests and investigations. Indicators for better utilisa-tion. Aust Fam Physician 1996;25:680–1.4. Bird S. Missing test results and failure to diagnose. Aust Fam Physician 2004;33:360–1.CoRRESPoNDENCE afp@racgp.org.auLessons in preventing errors relating to investigation processes•	 	Ensure	the	investigation	you	are	requesting,	or	the	report	upon	which	you are acting, corresponds to the correct patient•	 	Be	vigilant	in	your	practice	system	of	checking	and	acting	on	all	investigation results. Daily downloading and checking results electronically may avoid some of the errors related to unseen reports being accidentally filed or missing results being overlooked•	 	Use	recall	and	reminder	systems	in	your	practice	to	follow	up	outstanding investigation results from other providers and appropriately act upon all abnormal results that you receive.626  reprinted from auStralian FaMily phySician Vol. 37, No. 8, August 2008

Lessons from the TAPS study - Managing
            investigation results - is your practice system safe?

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Lessons from the TAPS study - Managing investigation results - is your practice system safe?

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