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Content analysis of 50 clinical negligence claims involving test results management systems in general practice

机译:一般实践中涉及测试结果管理系统的50个临床过失声明的内容分析

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Background and aims Laboratory test results management systems are a complex safety issue in primary care settings worldwide. Related failures lead to avoidable patient harm, medicolegal action, patient complaints and additional workload to problem solve identified issues. We aimed to review and learn from 50 clinical negligence cases involving system failures related to the management of test results. Methods The Medical Protection Society database was searched and a convenience sample of 50 claims identified from a 3-year period covering 2014–2016. A content analysis of documentation was undertaken to quantify and theme data, aided by a Risk Assessment Matrix and the Yorkshire Contributory Factors Framework. Quantitative data were subjected to simple descriptive statistical analysis. Results 14/50 cases (28%) involved a delay in diagnosis or treatment of a patient with cancer. 15 cases were judged to be ‘never events’ (30%) and 85 distinct system issues were identified. Just under half of cases involved a failure to notify patients of an abnormal test result (n=24, 48%), while 18 cases (36%) involved a test result not being actioned by a doctor. The most frequently occurring contributory factors (n=30, 60%) were related to local working conditions, for example, unclear professional responsibilities with regards to test result review or follow-up or lack of patient care continuity. Conclusion This small study highlights why test result management systems fail and contribute to future litigation, providing new insights in this area. Most claims involved avoidable harm to patients and preventable organisational risks. The findings point to the inadequate design of practice systems and the need for proactive strategies to improve the management of test results in order to reduce patient harm.
机译:背景和目的实验室测试结果管理系统是全球范围内初级保健机构中一个复杂的安全问题。相关的故障会导致可避免的患者伤害,法医学行为,患者投诉以及解决已解决问题的额外工作量。我们旨在回顾和学习50例临床疏忽案例,这些案例涉及与测试结果管理相关的系统故障。方法检索了医学保护协会的数据库,并从2014-2016年的3年期间中,抽取了50份索赔的便利样本。在“风险评估矩阵”和“约克郡贡献因素框架”的帮助下,对文档进行了内容分析以量化和主题化数据。定量数据经过简单的描述性统计分析。结果14/50例(28%)涉及延迟诊断或治疗癌症患者。 15例被判定为“从不发生”(30%),并确定了85个不同的系统问题。不到一半的病例未能将异常的检查结果通知患者(n = 24,48%),而18例(36%)涉及的检查结果没有得到医生的处理。最频繁发生的促成因素(n = 30,60%)与当地的工作条件有关,例如,对测试结果的审查或随访的专业责任不明确,或缺乏患者护理的连续性。结论这项小型研究突出了测试结果管理系统为何会失败并导致未来诉讼的原因,从而提供了该领域的新见解。大多数索赔涉及可避免的对患者的伤害和可预防的组织风险。研究结果表明,实践系统的设计不足,需要采取积极的策略来改善测试结果的管理以减少对患者的伤害。

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