Page 18 - APP Collaboration - Assessing the Risk (Part One)

SVMIC Advanced Practice Provider Collaboration: Assessing the Risk

Systems

The graph shows us that one-third of claims involved some type
of system failure, broadly defined as inefficient or wholly lacking

processes or mechanisms that serve as a safety net or fill a gap
in a faulty process.

A breakdown of the data shows 38 percent of the claims were

a result of failure to follow up or notify patients of abnormal
test results. Mishandled phone messages, failure to track test

results, and failure to follow up on missed appointments each
accounted for thirteen percent of claims. Retained foreign body

claims accounted for 8 percent and the remaining 16 percent
were a result of other systems failures. Examples include failure

to track a hospital discharge, scheduling/requisition mishaps,
contaminated specimens, and misread test results.

The objective is to design systems and processes to ensure that
they reliably “close the loop” between the ordering of tests or

specialty referrals and the return of that information back to the
provider who ordered it and, ultimately, to the patient.

Medication

Medication errors contributed to 28 percent of claims, with

administration issues representing 24 percent. Failure to monitor
and contraindicated medications accounted for 19 percent each.

Adverse reaction and controlled substance issue accounted for
10 percent each. Other medication issues (wrong dose, wrong

medication given, wrong medication prescribed, and refill
issues) represented the remaining 20 percent of the medication

issues.

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