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SVMIC Risk Basics: Surgical Practice
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.
2
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
postoperatively 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
2 The Agency for Healthcare Research and Quality (AHRQ)
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