Most Frequent Patient Safety/Risk Management Issues Identified in Our Closed Claims: Results of Our 2010 Site Surveys

In 2010, we provided personalized support with 525 patient safety site surveys. These were conducted across a range of practice environments around the country — from small office practices to large integrated delivery systems, hospitals, and outpatient facilities, such as surgery centers.

Our national scope gives us unparalleled insight into critical trends in every region of the country. This unique perspective guides us in creating clinical tools and programs that help our members identify risk and improve patient safety.

In 2010, we improved the discipline, rigor, and potential for system-wide learning with the introduction of our Interactive Guide for Office Practices, an innovative tool based on the most frequent patient safety/risk management issues identified in our closed claims.

What Did We Find?

Of the 15 categories in the Interactive Guide for Office Practices, medical record documentation was the category with the most frequent patient safety/risk management issues. A total of 266 surveys — more than half of the 525 site surveys — had at least one issue related to this category. Top findings within this category included the failure to document allergy status in the same location in each record and the lack of a problem list or a list of current medications.

We found that two combined categories — lab tests/referrals and scheduling/follow-up — came a close second with issues in 234 of the surveys. Although the categories are individually ranked fourth and fifth, they are so closely related that a finding in one typically leads to a finding in the other. The findings included a failure by the practitioner to review and sign all test results; no follow-up for missed appointments; and no tracking system to ensure that the ordered test was performed, the report received, the patient informed, and appropriate follow-up accomplished.

The third category identified medication management as an issue in 195 of the surveys. The issues in this category included medications that were drawn up in unlabeled syringes, absence of a system for storing and managing sample medications, and failure to ask patients for an updated list of current medications.

The fourth category identified confidentiality and privacy as an issue in 137 surveys. Examples of these findings are failure to secure medical records after hours and failure to obtain consent to leave messages on the patient’s answering machine.

Risk Tips for the Top Four Categories

1. Medical Record Documentation (an issue in 51 percent of surveys):

• Document allergy information in the same place on all medical records. If the patient has no allergies, document no known allergies (NKA).
• Maintain a current list of medications, including herbal supplements and over-the-counter medications.
• Maintain a current problem list with dates of problem identification, reviews, and resolutions.
• Use the patient’s own words when documenting. This is not only more informative to other physicians or staff but it also lends more credibility in the event of a legal proceeding.
• Make sure all pages are organized and that all forms are completed; do not use sticky notes or other loose papers for charting.
• Always indicate in writing or electronically that all results of tests, consultants, and referrals were reviewed, and maintain the reports in the same place in all medical records.
• Document all after-hours patient calls in the medical record.

2. Lab Tests and Referrals/Scheduling and Follow-up (an issue in 45 percent of surveys):

• Ensure that all members of your office staff know how to reconcile tests, referrals, and consult orders with the results when received. If a discrepancy occurs, have a process in place to remedy it promptly before an adverse event occurs.
• Do not rely on a return appointment or placing a “hold” on the medical record to act as a reminder that a test was not performed or the patient was not contacted about results.
• Communicate all test results to patients, including those that are within normal limits (WNL).
• Engage the patient in following up for test results. Tell the patient to contact your office if he or she has not received results from you or your office staff by a specified date.
• Use a recall system for those patients who are regularly seen.
• Send letters to patients who fail to follow up and cannot be reached by phone; file all documentation and copies of letters in the medical record.
• If using an electronic medical record, utilize the test tracking capability as designed.

3. Medication Management (an issue in 37 percent of surveys):

• Take time to make sure the patient understands the reason for the medication, how to take it, and when to contact your office if the patient experiences side-effects. Use repeat-back or teach-back techniques to confirm the patient’s understanding.
• Store medication samples, syringes, and prescription pads securely.
• Do not maintain unlabeled syringes, and do not leave them unattended. The medication should be immediately administered by the person who prepared it.
• If you prepare medications to be used later, make sure the person preparing the medication signs or initials the label and includes the name of the medication, the dosage, and the date.
• Ensure that medications requiring refrigeration are maintained at the correct temperature by keeping a record of who performs the checks and what was discarded.
• Ask the person receiving a verbal order to repeat back the order after he or she has written it.
• Identify all high-alert medications kept in your practice, and follow guidelines to ensure they are stored, ordered, dispensed, and administered correctly. Refer to the Institute for Safe Medication Practices website at www.ismp.org for more information on this topic.
• Refer to your state law to determine which staff can call in new prescriptions or refills. For example, medical assistants should not call in new prescriptions.

4. Confidentiality and Privacy (an issue in 26 percent of surveys):

• Provide education to all staff and practitioners on the requirements of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) on an annual basis.
• Use business associate agreements with vendors that have access to patient information.
• Do a personal check of areas within your office where conversations with patients can be overheard by others. Pay particular attention to whether a conversation in one treatment room can be heard in the next room.
• When faxing patient information, use a cover sheet that includes confidentiality language and provides contact information if a fax is received in error.
• Always knock before entering a treatment room. Make sure you do not leave a treatment door open when a patient is present.
• Do not leave messages on a patient’s voice mail unless you have been given specific permission to do so by the patient.

Most-prevalent Risks Identified in Selected Specialties

Family Practice:

• Medical Record Documentation: 59%
• Lab Tests and Referrals/Scheduling and Follow-up: 57%
• Medication Management: 30%
• Confidentiality and Privacy: 17%

Orthopedics:

• Medical Record Documentation: 65%
• Lab Tests and Referrals/Scheduling and Follow-up: 49%
• Medication Management: 40%
• Confidentiality and Privacy: 30%

OB/GYN:

• Medical Record Documentation: 79%
• Lab Tests and Referrals/Scheduling and Follow-up: 85%
• Medication Management: 46%
• Confidentiality and Privacy: 46%

Pediatrics:

• Medical Record Documentation: 10%
• Lab Tests and Referrals/Scheduling and Follow-up: 5%
• Medication Management: 82%
• Confidentiality and Privacy: 8%

Plastic Surgery:

• Medical Record Documentation: 64%
• Lab Tests and Referrals/Scheduling and Follow-up: 44%
• Medication Management: 33%
• Confidentiality and Privacy: 41%

Internal Medicine:

• Medical Record Documentation: 65%
• Lab Tests and Referrals/Scheduling and Follow-up: 58%
• Medication Management: 48%
• Confidentiality and Privacy: 26%