Page 24 - APP Collaboration - Assessing the Risk (Part Two)
P. 24
SVMIC Advanced Practice Provider Collaboration: Assessing the Risk
C A S E S T U DY
Another brief example with both communication and
systems failures leading to a tragic result, involved a
patient who underwent a cystourethroscopy for
complaints of hematuria. Urine cytology was collected
which revealed malignant cells. However, the report was
not transmitted to the office, nor did the lab call the office
to report the critical finding. There was no internal tracking
in place to alert the physician of the missing test result. A
return visit in six months was scheduled, but the patient
failed to keep his appointment. Again, the office had no
system to follow up on missed appointments. Nearly a
year later, the patient self-referred to another urologist
who diagnosed bladder cancer with brain metastasis.
Remember, the most common systems failure contributing
to patient injury is failure to track or follow-up ordered tests,
appointments, and referrals. Maintaining a system for tracking
test results, referred patients, and missed appointments is
essential to avoiding delays in diagnosis and/or treatment.
Medication
Another area of risk considered preventable is medication
errors. Medication is the number one patient treatment, and
unfortunately, it is high on the list of preventable error resulting
in patient harm. Often, these errors occur in your discussion
(or failure to discuss) medication regimens with patients.
Simply asking patients “Are your medicines the same?” often
leads to critical medical errors when patients are unaware of
Page 24