Risk Warning: test result management

Data from the NHS National Reporting and Learning System shows that more than 800 reported patient safety incidents relate to test result management. Sabina Khanom, Patient Safety Policy Lead (Primary Care) and Dr Martyn Diaper, Patient Safety Expert Advisor in General Practice, at NHS Improvement, and Julie Price, Medical Protection’s Head of Risk Management and Education Consultancy, examine the issue and provide advice on how to minimise this risk.

Read this article to:

• Find out the most common causes of patient safety incidents related to test result management. 
• Learn how to minimise your test result management risk. 
• Discover Medical Protection’s risk management tools that can support your practice further.

Test handling and result management in general practice is a complex process. It involves nearly every member of the practice team, while also relying on practice systems and outside providers. It is therefore not surprising that sometimes things go wrong. This can result in serious lapses in patient care, including delays in diagnosis and effective treatment.

A review of data from the National Reporting and Learning System (NRLS) highlighted 888 incidents in general practice between October 2015 and September 2016 relating to test management. The vast majority (92%) recorded no or low harm to the patient. However, such incidents may create additional work for the practice and unnecessary anxiety or inconvenience for the patient.

Eight per cent of incidents were reported as death, severe or moderate harm. But it is important to note that, due to the complexity of the patients’ underlying conditions, poor management of test results was not the only contributory factor. These examples include cases of stroke and cerebral bleeds, and significant delays in diagnosing cancer and Cauda Equina.

Review of the reported incidents highlights emerging themes, including: 

Communication failure

The largest proportion (31%) of incidents related to this theme. It includes delaying results or failing to communicate them to the practice or patient, or communicating incorrect results. This theme also includes communication failure when requesting a third party to undertake tests.

Example incident

A patient was admitted for investigation querying a pulmonary embolus. After discharge, a CT scan was performed to look for underlying malignancy. Despite repeated chasing, the results were not sent to the practice until six weeks after the scan, which revealed the patient had cancer. 

Incorrect sample labelling or request form

This includes samples or specimens sent for analysis unlabelled or with incorrect identifiers. It also includes incidents where the request form was missing or incorrectly completed, and where the label on the sample did not match the details on the test request form.

Example incident

A patient left a stool sample at the practice and a piece of paper recording only his name. Later that day another patient with a similar name left a urine sample. These were both sent for analysis under the second patient’s ID. This resulted in a delayed referral for the first patient. 

Delay or failure to act on test results

This includes test results communicated to the practice but not acted on.

Example incident

An elderly patient with comorbidities, under the practice’s care for warfarin monitoring, was noted on several occasions to have a Time in Therapeutic Range (TTR) below 40% without further action being taken. The practice was recently made aware that the patient subsequently died from a stroke.

Delay or failure to undertake tests

These may be for diagnosis or for ongoing routine monitoring.

Example incident

A chance finding highlighted a patient on long-term warfarin for atrial fibrillation had not had an INR check in over a year. An urgent test revealed an INR of six (outside the INR target range for atrial fibrillation according to NICE guidance).

Sample lost or damaged in storage or transit

Where a sample or specimen was taken but was lost, missing or damaged en route to its destination for analysis. This may be in the practice, or at any location while in transit. Example incident A patient had a smear test at the practice. A few months later the patient telephoned to see if results were back as she had heard nothing. No results were back and the lab was contacted. It confirmed it had not received the smear sample. The patient required a repeat appointment – it is not yet known if the delay caused harm.