The Doctor’s Company sells medical malpractice insurance to doctors. In 2010, it conducted 525 patient safety site surveys. The surveys were conducted across a range of practice environments around the country—from small office practices to large integrated delivery systems, hospitals, and outpatient facilities, such as surgery centers.
The survey found that in the 15 categories it surveyed, medical record documentation was the category with the most frequent patient safety/risk management issues. A total of 266 surveys—more than half of the 525 site surveys—had at least one issue related to this category. Top findings within this category included the failure to document allergy status in the same location in each record and the lack of a problem list or a list of current medications.
The research also disclosed that two combined categories—lab tests/referrals and scheduling/follow-up—came a close second with issues in 234 of the surveys. Although the categories are individually ranked fourth and fifth,searchers determined that the they are so closely related that a finding in one typically leads to a finding in the other.
The findings included a failure by the practitioner to review and sign all test results; no follow-up for missed appointments; and no tracking system to ensure that the ordered test was performed, the report received, the patient informed, and appropriate follow-up accomplished.
The third category identified medication management as an issue in 195 of the surveys. The issues in this category included medications that were drawn up in unlabeled syringes, absence of a system for storing and managing sample medications, and failure to ask patients for an updated list of current medications.
Go here to read more and to see an excellent list of tips on how health care providers can take steps to minimize the risks identified in the survey.