Page 8 - 2022 Risk Basics - Systems
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SVMIC Risk Basics: Systems
simple, right? It can be if everyone’s goals are aligned. Regardless of
the healthcare team’s size or resources, a dedicated team of healthcare
professionals and administrators is able to develop highly reliable
and effective systems to prevent patient harm. The desired result of
minimizing existing risk and taking steps to avoid anticipated risks can be
realized.
In medicine today, healthcare practitioners are concerned about missing
something or discovering that follow-up on a diagnostic test or specialty
consult fell through the cracks. Not having the opportunity to reverse
the course on a delayed or missed diagnosis, especially a life-altering
diagnosis, can haunt a physician and lead to a lengthy lawsuit.
Nothing represents these concerns better than a claim from a patient
or family of a failure to diagnose cancer. A recent review of professional
liability claims from across the United States shows that diagnosis-
related claims account for a higher percentage of dollar costs than any
other category. Diagnostic errors are the leading type of paid medical
malpractice claims; they’re almost twice as likely to result in a patient’s
death compared to other claims and represent the highest proportion
of total payments. It is encouraging that most diagnostic errors are not
2
the result of errors in medical judgment. Rather, most diagnostic errors
are caused by failure or delay in receiving test results, communicating
those results, and appropriately acting on them. It is important to develop
and maintain specific processes (systems), such as test ordering and
result interpretation followed by patient communication. In addition to
systems failures for test ordering and results, similar issues exist with
initiating, completing, and communicating the results of specialty referrals
as well as patients who miss follow-up appointments. The key strategy
to appropriately responding to such actionable information is referred
to as closing the loop. This means that all mechanisms are in place to
2 https://www.phyins.com/sites/default/files/images/magazine/Physicians%20Report-Spring-2021-Final.pdf
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