Page 24 - APP Collaboration - Assessing the Risk (Part Two)
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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



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