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Lack of Follow Up with “No Doc” ED Patient Leads to Patient Injury

March 26, 2021

“No Doc” patients (patients without primary care physicians) are often treated in the ED. In the following case, an on-call FP’s agreement to admit the patient to the family practice service, and her partner’s examination of the patient, established their responsibility for following up on results ordered by the ED physician.

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Filed under: Patient Care

Failure to Convince Patient of Urgency of Follow Up Leads to Patient Death

March 26, 2021

Although every step in test result management is important and interrelated, patient notification errors tend to result in more adverse events.1 Communicating a critical or significantly abnormal test result requires more than simply distributing the result to the patient. The patient should understand the criticality of the result and how to follow up. Communicating the urgency of the circumstances may require an extra effort if the patient has low health literacy or cognition deficits.

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Filed under: Case Study, Patient Care

Poor Test Result Communication Process Leads to Patient Injury

March 26, 2021

In the following case, a primary care practice accepted a trial offer of an electronic test result communication system from its outside laboratory. Because the office had previously relied on faxed reports from the lab, and continued to use that system during the trial, a hybrid system was in place at the time of the adverse event. Research indicates that the use of a hybrid test result system is associated with higher rates of failure to inform patients of abnormal test results compared to using a single system.1 Consider the ways in which better planning and implementation could have reduced the risk of patient injury in the following case.

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Filed under: Patient Care

Lack of Redundancy and Coverage Contributes to Patient Death

March 26, 2021

In the following case, a family practice patient was not advised of a significantly abnormal test result because the result came in on a Friday afternoon when no one was in the office. This situation can arise anytime an office is closed.

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Filed under: Patient Care

Avoid Ambiguity in Pathology Reports to Improve Communication

March 26, 2021

A pathologist’s main objectives in writing a pathology report are to communicate the diagnosis and create a permanent record.1 The entire purpose of specimen procurement and pathology consultation may be defeated if the pathology report is inaccurate, incomplete, difficult to read, or difficult to understand.2

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Filed under: Best Practices, Patient Care

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