Page 53 - Avoiding Surgical Mishaps Part 1

SVMIC Avoiding Surgical Mishaps: Dissecting the Risks

loop” with test results by adopting consistently used tracking

systems. A tracking system is a process that ensures test
results have been received and reviewed in a timely manner,

those results are communicated to the patient, and follow-up
treatment (if indicated) is provided, including the documentation

thereof.
5

Failure to follow up on abnormal test results is a recurrent issue
in surgical practices. The typical situation is illustrated by the

following case examples:

A 45-year-old male patient who was discharged post-
operatively without any action being taken on abnormal

results from an intraoperative culture developed a spinal
abscess requiring surgery.

A 28-year-old female patient was admitted with head trauma.

An MRI revealed a possible aneurysm, and the radiologist
suggested angiography. There was a communication

breakdown between the radiologist and the surgeon, and
the surgeon did not review the report. Six weeks later, EMS

transported the patient to the hospital in critical condition
with a ruptured aneurysm.

Maintaining a system within each office site for tracking test

results, referred patients, and missed appointments is critical.
Missed diagnosis is a top claim received at SVMIC, and tracking

of lab and diagnostic test results, as well as referred patients
and missed or canceled appointments, is essential to avoiding

5 The Agency for Healthcare Research and Quality (AHRQ)

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