Safety of care
Shifting practice settings makes following up investigations and monitoring medication tougher: Strategies for managing risks
Originally published December 2016
In all healthcare delivery settings, timely follow-up of investigations and medication monitoring is a cornerstone of safe medical care. Inadequate follow-up may lead to patient harm.
Although follow-up of investigations is a professional and legal obligation of the ordering physician, settings in which the ordering physician is not available when results are received pose unique challenges. For example, such circumstances often exist in walk-in clinics, urgent care centres, emergency departments, and locum practice, but all practices may be at risk at times.
As well, it is becoming increasingly common for physicians to work in practice settings where they are not always available. For example, the CMPA recognizes that locum medical practice — whether in primary care or specialty medicine — is growing. The 2010 National Physician Survey reported that 4.7% of general practitioners and 2.5% of specialists surveyed were in locum practice, while 20.9% of general practitioners and 12.5% of specialists reported having used a locum physician in the previous year.1 More recently, the Royal College of Physicians and Surgeons of Canada reported that in 2011/2012 16% of physicians with specialist and subspecialist certificates were unable to secure a permanent position at the end of their training, and almost 22% of new graduates stayed employed by combining multiple locums or part-time positions.2
About one-third of the CMPA’s clinical medical-legal cases that closed in the last five years (4,174/13,899) 3 involved a diagnostic- or medication-related issue, or both. Twenty per cent of these involved problems in follow-up, the majority (63%) of which were specifically related to inadequate follow up of a diagnostic investigation or medication. Medical regulatory (College) complaints were the most common type of case, making up 51% and 60% of diagnostic and medication follow-up cases, respectively; followed closely by legal actions (46% and 32%, respectively); and a small number of hospital complaints (3% and 8%, respectively). The vast majority (>85%) of cases had an unfavourable outcome for physicians.
Family and emergency physicians were most often involved in these cases, followed by medical and surgical specialists (figures 1 and 2). Several cases specifically involved locum, primary care, or specialist physicians.
While most physical outcomes were considered relatively minor, 20% of patients were left with a major or catastrophic injury, and 28% died.
A closer look at diagnostic cases
A failure or delay to follow up on diagnostic tests most often resulted in delayed diagnosis or treatment of conditions, usually cancer. Several cases specifically involved locum primary care or specialist physicians. Peer expert criticism in these cases identified the following themes:
Provider factors (individual and team)
- Physician lacked:
- timely follow-up of diagnostic tests
- a system to ensure consistent follow-up of investigations
- familiarity with EMR system leading to incomplete information review
- Physician failed to consider another disease process despite continued or worsening symptoms
- Care team lacked:
- coordination (e.g. miscommunication and inadequate handover between multiple care providers)
- clarity as to the most responsible physician and who was responsible for follow-up and communication of the results
- communication of discharge instructions to the patient
- documentation of the management plan
System factors (office and hospital)
- Noncompliance with, or lacking a system intended to prevent errors in test follow-up
- Inadequate or absent critical results protocol
Case example: Abnormal mammogram results not communicated
A 53-year-old female with a family history of breast cancer undergoes a screening mammogram at a breast screening program (BSP) facility. The radiologist notes a suspicious lesion and dictates a report describing the lesion and recommending further imaging.
The BSP generates a standardized letter to the patient’s family physician (FP) that erroneously states the mammogram was negative. When the patient returns to her FP’s office for follow-up a few weeks later, she is seen by a locum, who advises her that the BSP letter states that the mammogram was negative. He does not review the radiologist’s report, which is attached.
When the FP returns five months later, he discovers the report of the abnormal mammogram and arranges for further imaging, which confirms cancer. The patient files a College complaint against the radiologist for the inaccurate letter, and the locum for failing to adequately review the mammogram results. Although the College considers the error to be due to a system issue with BSP, the radiologist is advised to institute quality assurance processes in the BSP and to ensure the ordering physician is notified of abnormal findings and follow-up recommendations in a timely manner. The locum is advised to ensure the review of all pages of test results prior to filing.
A closer look at medication cases
Inadequate monitoring of medication adverse effects or therapeutic drug levels contributed to significant patient harm. Opioids were the most commonly involved agents, followed closely by psychotropic agents (anxiolytics, antipsychotics, antidepressants). Similar numbers of cases involved aminoglycoside antibiotics and antithrombotic agents. A few cases involved anti-inflammatory agents, corticosteroids, or sex hormones. Peer expert criticism in these cases identified the following themes:
- Inadequate history and medication reconciliation leading to:
- prescription of an agent with relative or absolute contraindication, polypharmacy, dependency
- failure to recognize serious drug interactions
- Inadequate monitoring for toxicity and/or efficacy of prescribed medication
- Failure to recognize when confronted with known drug adverse effects or unanticipated adverse effects
- Inadequate or absent documentation of the rationale for and discussions surrounding the decision to continue, discontinue, or modify the posology—the dosing and scheduling of a medication
System factors (office and hospital)
- • Noncompliance with, or lack of a system to prevent follow-up issues, including:
- therapeutic drug monitoring (TDM) protocol lacking clarity as to who was responsible for action
- absent recall system leading to failure to follow up TDM flags or toxicity
- inadequate or absent quality assurance protocol in the pharmacy
- Lack of coordination between multiple care providers
Case example: Missed blood culture results lead to incorrect antibiotic choice
A young adult male who had years earlier undergone open reduction and internal fixation of a tibial fracture presents to the emergency department (ED) with signs of infection following trauma to the leg. Cultures were taken and the ED physician, suspecting osteomyelitis, prescribes IV vancomycin and gentamycin. The patient is discharged with surgery scheduled for the following week.
Cultures grow beta hemolytic streptococcus sensitive to cefalozin, but the results were not reviewed as the ordering physician was not identified.
A week later, an orthopaedic surgeon performs a debridement and hardware removal. He orders continuation of antibiotics for six weeks, without knowing which antibiotic the patient is taking. Over the next several days, the patient presents to the ED multiple times for antibiotic infusions. He develops a rash, his gentamycin levels are found to be supratherapeutic, and his creatinine is rising. His dose of gentamycin is adjusted and he is treated with IV fluids and IV diphenhydramine.
Two weeks post-surgery, an infectious disease specialist, upon reviewing the original culture results, recommends discontinuing the gentamycin and vancomycin and starting the patient on cefazolin. These orders were not actioned. Four days later, the patient presents to the ED with dizziness and signs of renal failure. It is at this point that the antibiotics are changed. The patient files a legal action alleging that poor follow-up left him with permanent otovestibular and renal damage. A settlement is paid to the patient by the CMPA, on behalf of the physicians, and by the hospital, on behalf of the pharmacist.
Risk management considerations
Inadequate follow-up of investigations and medication monitoring can occur more frequently in shifting practice settings and may lead to considerable patient harm. In addition to heightened situational awareness, experts consulted on our medical-legal cases suggested the following strategies for physicians working in these settings:
- a system capable of the timely tracking of all investigations ordered, and linking them to the corresponding results as "received," "reviewed," and "actioned"
- a process to ensure that abnormal test results are communicated to other healthcare providers involved in the patient’s care
- a process for managing misdirected test results
- Ensure clarity as to who is responsible for follow-up and action of investigations, particularly at transition points (e.g. discharge from hospital, handovers of care)
- Familiarize themselves with the existing EMR systems in each practice setting
- Carefully document:
- the management plan and instructions provided to the patient
- the review of investigations and action undertaken
- the rationale for and discussions surrounding the decision to continue, discontinue, or modify the posology of a medication
- Engage the patient in their care by:
- highlighting the importance of follow-up and the need for a return appointment at which they should seek confirmation of test results
- informing them of who is responsible for their care
- explaining the pharmacologic management of their condition, including the need for regular or increased monitoring
- College of Family Physicians of Canada, Canadian Medical Association, Royal College of Physicians and Surgeons of Canada. National Physician Survey, 2010 [Internet]. Mississauga: National Physician Survey; 2010 [cited 2016 Apr 22]. Available from: http://nationalphysiciansurvey.ca/wp-content/uploads/2012/05/NPS2010-National-Binder.pdf
- Fréchette D, Hollenberg D, Shrichand A, Jacob C, Datta, I. 2013. What’s really behind Canada’s unemployed specialists? Too many, too few doctors? Findings from the Royal College’s employment study [Internet]. Ottawa: The Royal College of Physicians and Surgeons of Canada; 2013 [cited 2016 Apr 22]. Available from: http://www.royalcollege.ca/rcsite/documents/health-policy/employment-report-2013-e.pdf
- Legal, college, and hospital cases, closed between 2011 and 2015, identified by highest case type.