Mistakes Happen: Identifying and Addressing Factors that Contribute to Missed Test Results and Inconsistent Follow Up
Missed and delayed test results are one of the most common issues leading to medical malpractice claims. This workshop addresses the issue by walking through specific examples investigating missed or delayed test results using a root cause analysis method. It is designed for all levels of experience in root cause identification to improve their effectiveness. We will briefly review and then use an investigative model based on recently published medical research. Participants will follow along in a workbook as we review hypothetical scenarios. Their investigation will reveal barriers in information flow and identify relationships between contributing factors. After highlighting the causes, we will develop proactive strategies to address the identified issues. Participants will leave the program with a worksheet template that can be implemented immediately to aid their risk reduction efforts. There will also be an optional, individual follow-up consultation scheduled after the program where participants can review an investigation worksheet (deidentified of protected health information) that they completed after the program.