Page 58 - Avoiding Surgical Mishaps Part 1

SVMIC Avoiding Surgical Mishaps: Dissecting the Risks

The following case example illustrates systems failures for both

tracking labs and missed appointments. In this case, it appeared
there was no system to track at all.

CASE STUDY

A 44-year-old patient underwent a cystourethroscopy for
complaints of hematuria. Urine cytology was collected

which revealed malignant cells. However, the report
was not transmitted to the office, nor did the lab call the

office to report the critical finding. There was no internal
tracking in place to alert the physician of the missing test

result. A return visit in six months was scheduled, but the
patient failed to keep his appointment. Again, the office

had no system to follow up on missed
appointments. Nearly a year later, the

patient self-referred to another urologist
who diagnosed bladder cancer with brain

metastasis.

Tracking Systems

Tracking procedures should be simple, organized, and
consistently used by all providers in the practice. Staff should be

trained and accountable for accurately maintaining the system.
It should be understood by everyone that once the tracked tests

or reports are received, they must be handled appropriately by
following one of the following recommended processes.

Electronic Records

• If tests or reports are received via hard copy, they should
be reviewed and initialed by the physician and his/her

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