Tracking and Recall Systems Can Save a Life

Physicians and their staff often mistakenly believe they have systems in place to protect their patients to ensure that care is coordinated and timely. The reality is that many of these office systems are insufficient and allow patients and/or their test results to fall through the cracks. Effective tracking and recall systems are lifesaving processes engineered to ensure timely follow up on patients, referrals, laboratory results, and imaging studies.

Diagnostic error is the most common reason for a paid malpractice claim in the ambulatory setting.Although diagnostic errors frequently involve errors in cognition and clinical judgment, they can also result from wholly preventable deficiencies in office systems — specifically, in the management, transfer, and communication of clinical data.

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According to Dr. Peter Birnstein, who chairs CAP's Risk Assessment Peer Review Committee, "In Risk Assessment Peer Review, we see the same scenarios playing out over and over, resulting in diagnostic delays, devastating patient injury and lawsuits. These scenarios involve failures in tracking and recall systems in which patients themselves and/or important clinical data — just fall through the cracks. These failures cut across all specialties!

"When we ask the member if he or she has a tracking system in their office, invariably they’ll answer, “Yes!” After further discussion, we realize that their tracking systems are insufficient because they are not designed to detect or safeguard against failure.

"Whether it’s a patient, a laboratory result, or an imaging study, there needs to be a way to timely identify if the test result is delayed or missing, or if the patient has failed to return to the office for follow-up. This allows the practice to intervene. The ability to timely detect failure and take action is essential to a robust tracking system.”

The following examples illustrate how the absence of tracking systems can cause delay in diagnosis:

1.  Laboratory tests or diagnostic imaging are ordered, but there is no mechanism in place to compare ordered tests with those received by the office. Therefore, the missing test results go unnoticed. Additionally, there is no protocol for physician review of results and/or communication to the patient.

2.  The plan includes referral to a specialist. There is no process for tracking referrals and no way of knowing if this consultation occurred.

3.  There is no process for recalling patients with high-risk conditions requiring regular follow-up. Examples may include patients with a history of cancer, diabetes, hypertension, or those who require reminders of screening tests such as mammograms and colonoscopies.

Tracking and recall systems are essential to preventing patients and clinical data from being lost to follow-up. Like any critical alarm system, a tracking or recall system should detect missing data and disruptions in care early enough to enable the practice to intervene.  

There is no singular, optimal tracking system. For a tracking system to be effective, it must work for your office and be implemented consistently!

Tracking Laboratory Tests, Diagnostic Studies and Referrals.

  • Develop an office policy to track tests and referrals. The policy can include the expected time frames for results, the frequency for reviewing tracking logs, documentation standards, and the protocols for managing missing reports. 
  • An important aspect of any tracking system is that it is maintained outside of the medical record. In other words, to detect that a patient’s results have failed to return to the office, one should never have to access information within the patient’s medical record.
  • Tracking systems need not be fancy. They can be log books, lists in laboratory interfaced systems, or alert lists within the electronic medical record. At a minimum, they should include the test or referral ordered, the date ordered, and the patient’s name. Once received, results should be reviewed, signed, and dated by the ordering physician with any action noted and filed or scanned into the patient’s medical record. Patients should be notified of all test results ― even those that are normal.
  • As a secondary safeguard, educate patients that the office contacts patients about all their laboratory results. Patients should be instructed to call the office if they don’t hear the results of tests in a timely fashion to prevent the assumption that “no news is good news.” 

The Missed Appointments Safety Net

An important aspect of ensuring patient safety and reducing liability exposure is ensuring patients follow up as recommended. Consider the following measures to keep patients from “slipping through the cracks”:

  • Schedule high-risk patients and time-sensitive follow ups before they leave the office. This simple practice ensures the patient is “in the books.” If patients refuse to schedule a follow-up appointment before they leave your office, enter their names on a call-back list to contact them later.
  • Use appointment reminders to improve follow-up and decrease “no-shows.” Every missed appointment is a missed opportunity to reevaluate the patient.
  • When patients don't show, activate the missed appointment protocol: staff should attempt to contact patients who miss their appointment, document the reason for the missed appointment, and reschedule the visit. Additionally, staff should inform the physician or provider of any patient who misses an appointment. The physician should decide what action to take depending on the patient’s reason for the visit and medical history. Some patients may require more aggressive follow up, such as a physician call or a certified letter explaining the risks of failing to follow up.

Communicate and Document!

Compliance and outcomes greatly improve when physicians educate their patients and discuss the rationale for their treatment recommendations. Documenting one’s efforts to educate demonstrates professionalism and your respect for the patient’s right to information. Further, when patient education and attempts to reach the patient are not documented, the defense is greatly compromised, and the physician is vulnerable to allegations that these activities never occurred.

Patients-turned-plaintiffs commonly allege that they were noncompliant because they were never properly educated about the treatment plan or the consequences of deviating from it. “I didn’t know. I wasn’t told. Had I known, I would have followed the physician’s treatment recommendation” are statements that resonate with lay jurors, who are patients themselves. Therefore, resistance on the part of the patient may require communication from the physician in the form of a well-documented phone call or a certified letter, whereby associated risks of not following the plan are clearly explained.

Countless incidents of diagnostic delays and severe patient injury occur because of preventable failures in tracking and recall systems. Understanding the essential elements of a robust tracking and recall system can save a life and prevent a lawsuit. To assist you in assessing your office systems and keeping your patients safe, contact CAP's Risk Management and Patient Safety Department at 800-252-0555.  

 

1 Bishop TF, Ryan AK, Casalino LP.  Paid malpractice claims for adverse events in inpatient and outpatient settings. JAMA 2011;305:2427-2431.