Page 12 - 2022 Risk Basics - Systems

SVMIC Risk Basics: Systems

The general categories of system failures discussed in this course

include:

• Failure to follow up on:

» Lab or diagnostic imaging results

» Referrals to other providers

» Missed or canceled appointments

» Previously identified abnormal conditions

• Failure to notify patients of results and needed treatment

• Mishandling phone calls

Have you considered the responsibility for closing the loop on tests or

referrals you order? As well as your responsibility for tracking those tests
and notifying the patient of all test results? If the ordering physician
fails to do so, does any responsibility flow to the next provider in line, for

example, the physician’s nurse practitioner (NP)? Does responsibility flow

outward to other providers who were not involved in ordering the test but
who are in receipt of results? Unfortunately, if someone drops the ball,
these questions may be answered by a judge or jury in a negative way.

The following is a case that illustrates each of the areas of ineffective or

nonexistent systems to be discussed in this course.

C A S E S T U DY

Eliza Jones was a 70-year-old female, post-CABG (at age 67) with

multiple health concerns as well as evidence of early dementia.
Along with Aricept for diminished mental capacity/Alzheimer’s
type, Mrs. Jones was placed on low-dose aspirin, Coumadin, and

Plavix by her cardiologist, Dr. Aaron Smith, for atrial fibrillation. No

clear-cut plan for lab work or anti-coagulation parameters were

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