Lessons from the TAPS study--managing investigation results--is your practice system safe?
ABSTRACT The TAPS study found that errors in the process of providing health care were reported by general practitioners more than twice as often as deficiencies in a clinician's knowledge or skills. Approximately 20% of these process error events concerned investigations. In addition, some reported events that related to investigations included filing system and recall errors, which accounted for a further 10% of reported error events.
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the tapS study found that errors in the process of providing
health care were reported by general practitioners more than
twice as often as deficiencies in a clinician’s knowledge or
skills. approximately 20% of these process error events
concerned investigations. in addition, some reported events that
related to investigations included filing system and recall errors,
which accounted for a further 10% of reported error events.
errors in the management of investigation results
The TAPS study collected 648 reports from a representative sample of
New South Wales GPs.1 There were several areas described where
processes around investigations had failed.2 The most problematic
area in terms of potential for harm was related to the management of
investigation reports. This occurred when investigation reports were
filed before the GP had seen them, GPs missed an abnormal result
(for example on a second page of a report), and abnormal results were
noted by the GP but then not followed up.
The Australian Critical Incident Study of the mid 1990s identified
four stages where incidents relating to tests and investigations
were commonly found to have occurred: arranging the test, the
testing process, communication of results to GPs, and follow up of
results with the patient.3 It was found that over half of the incidents
associated with investigations could probably have been prevented
through more efficient systems for maintaining and passing on test
results, and recalling patients for follow up.
Michael r Kidd
MBBS, MD, FRACGP, is Professor
and Head, Discipline of General
Practice, The University of Sydney,
New South Wales.
charles Bridges-Webb aO
MBBS, MM, MD, FRACGP, is Director,
The Royal Australian College of General
Practitioners NSW Projects, Research and
Evaluation Unit, Sydney, New South Wales.
Meredith a B Makeham
BMed(Hons), MPH(Hons), PhD, FRACGP, is
Clinical Lecturer, Discipline of General Practice,
The University of Sydney, New South Wales.
lessons from the tapS study
Managing investigation results – is your practice
General practices need systems in place to ensure
that investigation results are received, checked,
communicated to patients and appropriately acted upon.
Clinicians in any setting must take responsibility for
ensuring that all results are checked and that action has
been taken regarding all investigations that they have
performed or requested.
A woman, 72 years of age, presented to a hospital
emergency department with a history of abdominal
bloating, reflux and discomfort over many months. Nine
months previously she had been referred by her GP to a
hospital outpatient clinic for a gastroscopy. On the day of
the procedure, the patient was told by a hospital registrar
that all appeared normal, and she had ceased her proton
pump inhibitor medication. The gastroscopy report was
sent to the GP, and said: ‘normal, biopsy sent’. When the
patient's hospital notes were reviewed 9 months later
in the emergency department, the histopathology report
suggested that there was mild gastritis with the presence
of Helicobacter pylori. The GP had not seen a copy of
the histopathology report and the patient had not been
notified of the abnormal result by anyone at the hospital.
The Threats to Australian Patient Safety (TAPS) study collected
648 anonymous reports about threats to patient safety from a
representative random sample of Australian general practitioners.
These contained any events the GPs felt should not have happened,
and would not want to happen again, regardless of who was at fault
or the outcome of the event. This series of articles presents clinical
lessons resulting from the TAPS study.
This report illustrates the need for systems that
ensure that all abnormal investigations are followed
up. The abnormal histopathology findings were not
communicated to either the patient or the GP by the
hospital clinician involved in this case. A flag on the GP’s
file that the biopsy results were outstanding may have
prompted the GP to chase up this result.
reprinted from auStralian FaMily phySician Vol. 37, No. 8, August 2008 625
lessons from the tapS study – managing investigation results – is your practice system safe? clinical practice
claims arising in general practice result from a failure to diagnose a
patient’s condition, and these claims commonly arise from a failure in
the practice’s test result management system.4
The case study presented also highlights a failure in hospital
communication with general practice, which was a common finding
in the TAPS study. This type of error accounted for close to 10% of all
process error events reported.2
In terms of medicolegal risk, up to 50% of medical negligence
errors in investigation processes found in the tapS study
infection based on another patient’s investigation results that had
been incorrectly filed
investigation for a patient and accidentally putting the details of
another patient on the form
report and missing the report of abnormal pathology.
Conflict of interest: none declared.
The TAPS study was funded by a NHMRC PHC project grant. Meredith Makeham
was a NHMRC scholar and received additional support under the Researcher
Development Program, PHC RED Strategy, funded by the Commonwealth
Department of Health and Ageing.
1. Makeham MA, Kidd MR, Saltman DC, et al. The Threats to Australian Patient
Safety (TAPS) study: incidence of reported errors in general practice. Med J Aust
2. Makeham MA, Stromer S, Bridges-Webb C, et al. Patient safety events reported in
General Practice: A taxonomy. Qual Saf Health Care 2008;17:53–7.
3. Bhasale A, Norton KJ, Britt H. Tests and investigations. Indicators for better utilisa-
tion. Aust Fam Physician 1996;25:680–1.
4. Bird S. Missing test results and failure to diagnose. Aust Fam Physician
Lessons in preventing errors relating to investigation processes
•? ? Ensure?the?investigation?you?are?requesting,?or?the?report?upon?which?
you are acting, corresponds to the correct patient
•? ? Be?vigilant?in?your?practice?system?of?checking?and?acting?on?all?
investigation results. Daily downloading and checking results
electronically may avoid some of the errors related to unseen reports
being accidentally filed or missing results being overlooked
•? ? Use?recall?and?reminder?systems?in?your?practice?to?follow?up?
outstanding investigation results from other providers and appropriately
act upon all abnormal results that you receive.
626 reprinted from auStralian FaMily phySician Vol. 37, No. 8, August 2008