Page 67 - 2022 Risk Basics - Systems

SVMIC Risk Basics: Systems

was given at discharge. However, the cardiologist did not review the

discharge summary. If he had done so, this would likely have prompted
immediate action to contact the patient. Additionally, the patient was

seen by different cardiologists after his discharge, and the amiodarone
dosage was not verified at any of these office visits. And, finally, the

abnormal lab results had no follow-up.

Conclusion

The goal of this course was to give you an overview of risk issues
and factors contributing to systems failures resulting in patient injury.

We examined cases in which medical errors were not the result of a
healthcare practitioner’s knowledge deficit, lack of clinical judgment

or medical expertise, or failure to consider the correct diagnosis as
a possibility. Rather, the error was the result of a poorly designed or

neglected system. It is our hope that this course reminds you to evaluate
your current systems and processes and ensure they are effective and

consistently followed.

• Be sure you have an effective tracking method for all lab tests and

diagnostic imaging. If a test or consult is important enough to order,
it’s important enough to track and personally review.

• Implement a tracking system for patients who miss or cancel
scheduled appointments so that appropriate efforts are made to

contact the patient and reschedule the appointment in situations
where the patient may suffer if treatment is delayed or where the

treatment or medication must be monitored closely.

• There should be a consistent method for notifying patients of ALL

test results and instructing them to call the office if they have not

received the results within the expected timeframe.

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