Risk Tip: How Safe is Safe Enough?

Is your office practice’s process as safe as it could or should be?

Data from 525 site surveys in small office practices, large integrated delivery systems, hospitals, and in outpatient facilities, such as surgery centers using a standardized office assessment tool revealed that medical record documentation was the category with the most frequent patient safety/risk management issues followed by medication management, confidentiality and privacy, lab tests and referrals and scheduling and follow up. These last two categories are closely related, so a finding in one usually leads to a finding in the other.

• Document allergy information in the same place on all medical records.
• Maintain a current list of patient medications, including herbal supplements and over-the-counter medications.
• Indicate in writing or electronically that all results of tests, consultants, and referrals were reviewed, and maintain the reports in the same place in all medical records.
• Do not rely on a return appointment or placing a “hold” on the medical record to act as a reminder that a test was not performed or the patient was not contacted about results.
• Communicate all test results to patients, including those that are within normal limits (WNL).
• Avoid leaving messages on a patient’s voice mail unless you have been given specific permission to do so by the patient.
• Tell the patient to contact your office if he or she has not received results from you or your office staff by a specified date.
• Send letters to patients who fail to follow-up and cannot be reached by phone; file all documentation and copies of letters in the medical record.
• Initial or sign labels of medications prepared prior to use, and include the name of the medication, the dosage, and the date.
• Identify all high-alert medications kept in your practice, and follow guidelines to ensure they are stored, ordered, dispensed, and administered correctly. Refer to the Institute for Safe Medication Practices Web site at www.ismp.org for more information on this topic.
• Provide education to all staff and practitioners on the requirements of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) on an annual basis.
• Do a personal check of areas within your office where conversations with patients can be overheard by others. There are office buildings in which a conversation in one treatment room can be heard clearly in the next room.

Using data analysis from many sources enhances the ability to identify frequent loopholes in office practices and provide the most current and accurate patient safety information possible. March 6-12 is Patient Safety Awareness Week. For online tools such as the office practice assessment, National Patient Safety Foundation tools and more tips, visit www.thedoctors.com.

Contributed by The Doctors Company. The Doctors Company is the exclusively endorsed professional liability insurer for members of the Ohio State Medical Association. For more information the OSMA partnership with the Doctors Company, click here.