Page 15 - 2020 Risk Reduction Series Effective Systems_Part 1_Flipbook
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SVMIC Risk Reduction Series: Effective Systems
CASE STUDY
continued
discontinue her Coumadin. This was disputed by the
technician, and there was no telephone record indicating
such a call. Mrs. Jones’ family testified that they were not
notified by anyone of the result or told to discontinue the
Coumadin.
Dr. Carter testified that he firmly believed
neither he nor his NP had a duty to monitor
a medication prescribed and monitored by
a specialist, even after receiving the critical
value lab report.
Each physician and NP are highly regarded within the
healthcare community, but failures in communication regarding
which provider is managing the condition, poor documentation,
medication reconciliation, tracking and notification of test
results, documenting after-hours calls, patient education, and
responsibility for ordered tests led to a tragic result.
Tracking Procedures
Many of these failures could be prevented by employing highly
reliable and consistently followed tracking procedures. The
most common failure contributing to patient injury is failure to
track or follow up on ordered tests, appointments, and referrals.
Maintaining a system for tracking test results, referred patients,
and missed appointments is essential to avoiding delays in
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