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Patient Safety And Clinical Skills

Why this topic is important

• Failures in the systems-management of laboratory tests, clinical investigations and results handling in primary care are a significant cause of harm to patients and have been identified by the World Health Organisation as a major risk in health care systems.

• We know from the limited research in this area that common systems-based deficiencies include tests results with significant clinical findings going missing or not being returned to the individual who initiated the test, or test results being filed by administrative staff without a clinical decision being made.

• Systems for communicating test results and the responsibility for taking action are often poorly understood or implemented.

• The consequences and impact of such failures are multi-faceted: for patients this can mean missed or delayed diagnoses and potentially avoidable harm; for the practice team this can mean receiving a formal complaint and also necessitate the requirement to undertake significant event analyses; for individual clinicians this could also mean a complaint to local health authorities or regulators and the possibility of legal action.