Focusing on Patient Safety

by Joan Bristow, Vice President, Patient Safety and Loss Prevention

Patient safety is uppermost in the mind of every health care provider. By fine-tuning the systems in your practice, you can improve patient safety and achieve better treatment results. To help you achieve those goals, this article will concentrate on ways to enhance your office systems that have a direct influence on patient safety—treating minor patients, telephone communications, medication administration, and diagnostic workups.

Minor Patients

There are five major scenarios to consider in the treatment of minor patients: without a parent present, with stepparents, with foster parents, with divorced parents, and with emancipated minors. For each scenario, you can maximize patient safety and appropriate patient health care by:

• Providing treatment during situations that are emergent or even urgent. It is far easier to defend the provision of care without authorization than to defend the omission of care.
• Identifying emancipated minors. Emancipated minors include those patients who are pregnant, married, and legally free and financially independent, as well as those serving in the military.
• Asking the custodial parent to sign an authorization statement allowing treatment to be rendered by the practice without his or her presence—even when the minor patient arrives alone or with an adult who does not have custody. The form should be dated and be effective for a specific period of time.

At the time of each minor patient’s initial registration and annually thereafter (or whenever family changes occur), it is important to identify the person having primary custody of the patient. With today’s patient population, custody will vary: foster parents, stepparents, and divorced parents are now the norm. Divorced couples with equal custody should be asked to decide which parent will have primary status to offer the best possible scenario for the minor patient. By learning this information at the outset of care, continuity of care and, thus, a good outcome become easier to achieve.

The signed authorization statement also identifies the person who has the right to receive medical information. By establishing the recipient of medical record information in the beginning, you can effectively decrease the time and effort it takes your office to provide information and reports to multiple parties.

For office visits by unaccompanied minor patients, develop a method or a system to provide information related to the chief complaint, exam findings, diagnosis, and treatment plan to the person who has primary custody.

Telephone Communications

The telephone can be the most useful tool in your practice—or it can be a lethal weapon. All physicians and office staff should be aware of the pitfalls associated with this piece of equipment. There are several relevant points for discussion of phone use: after-hour patient calls, calls with medical care content, incoming calls for medical triage, answering services and systems, and on-call covering physicians.

After-Hour Patient Calls
You might receive a patient call at any time—during an evening out, in the middle of the night, or when you’re attending a school soccer game. All of these times conflict with the ability to write thorough notes concerning the nature of the call. What recourse do you have?

Keeping a small notepad in your pocket gives you a way to jot down enough information to remind you of greater details the next day in the office, when a full and complete note can be written or dictated. You can also carry a small handheld dictation device that makes it easy to transfer the information to the record during the light of day. Whatever method you select, remember that after-hours phone calls are an important factor in the care of your patients, as they undoubtedly pertain to medical care with orders.

Patients call physicians’ offices for many reasons: to make, cancel, or reschedule appointments, inquire after test results, request additional educational materials—and the list goes on. Is it necessary to record these calls in the progress notes of the medical record? No. It is, however, necessary to use a log to ensure that the intent of each call was completed and that the caller was satisfied with the action taken.

Medical Care Calls
Documentation requirements change when a call focuses on conditions of medical care. This type of call must be documented in the medical record to include the nature of the inquiry, the person to whom the caller was referred, a tentative diagnosis, and the action plan established to resolve the issue.

Develop written policies and procedures to ensure that every staff member realizes the importance of medical care calls and knows how to handle them:

• Begin a practice of immediately forwarding calls of this type to the licensed provider who will be able to handle the call.
• Pull the medical record, and document the date, time, patient name, and nature of the call in the progress notes ASAP.
• Make sure that the record is available to the person handling the call to ensure that allergies are known or that previous chronic conditions will not interfere with a new diagnosis.
• Keep the action circle open until the medical care issue has been resolved.
• Remember to perform follow-up activities during the next patient visit, including testing results ordered at the time of the call.

Medical Triage Calls
Emergent or urgent calls that require triage should be immediately directed to a licensed provider. No one except licensed personnel should perform triage or give medical advice over the phone. Make sure that you have written, physician-approved protocols in place.

Develop written protocols for the major types of emergent or urgent calls that come into your office most frequently, and develop an appropriate response or action for each.

Train and educate office personnel regarding how to identify and direct incoming calls efficiently, making sure that the calls are documented for follow-up if necessary.

Answering Services and Systems
Answering machines, services, and pagers are often a necessary evil in the practice of medicine. Although these technologies have become standard, physicians must be aware of possible pitfalls to avoid losing patient contact.

Here are several patient safety tips:

• Be prepared for utilities interruptions by having alternatives to electricity loss for the answering machine.
• Put an answering service through your own credentialing process to ensure its reliability.
• Test your pager at regular intervals.
• Challenge the process, and make a change if you have any doubt about the service or system you use.

On-Call Covering Physicians
On-call doctors pose a different problem with regard to phone services. When you ask another physician to handle your weekend calls, be sure that he or she has the same specialty and knowledge as you. Provide a list of acute or potentially emergent issues they might encounter. If at all possible, make sure that the on-call physician has access to any medical records he or she might need. Ask the on-call physician to provide you with a record of the calls that he or she fields for you.

Medication Administration

Despite adhering to the five Rs for administrating medications (right patient, right medication, right dosage, right route, and right interval/frequency), many patient safety hazards still lurk within this broad category. The topics we’ll discuss here are medication allergies, prescription errors, medication refills, herbal therapies, and sample drugs.

The first step in avoiding medication errors is to obtain a full and complete history of the patient’s medications. This information should be updated with every visit. An accurate and updated medical record provides a sound basis for patient safety.

Medication Allergies
Medication allergies reported by a patient during the intake history should be pursued to determine whether it is a true allergy or if the patient is describing a side effect. Document the reaction that the patient describes to allow the physician to make a medical judgment on allergy status. To eliminate the possibility of prescribing the wrong medications, make sure that allergy information is prominently placed in the medical record.

Prescription Errors
Prescription errors are easily avoided. Hand-held personal digital devices that link to a pharmacy can reduce errors caused by illegible handwriting or inappropriate or conflicting medications, and they can even alert you to medications that are not approved by a third-party payer.

If you use prescription pads, make sure that they are inaccessible to patients or staff without direct patient care. Handwritten prescriptions must be legible. If your handwriting is difficult to read, print your instructions. Make sure that you explain the rationale for your orders to the patient, as this will increase the chances of a more successful outcome. Pay attention to calls from your pharmacy that might indicate problems with the legibility of your prescriptions.

Medication Refills
Medication refills can be tricky when not placed under some measure of control by the practice. It is not unusual for patients to develop their own schedule for requesting refills—a schedule that might not be appropriate, or even safe, for the patient. When refills follow no set pattern, the opportunity for abuse is rampant. The following measures, when consistently applied, will ensure greater patient safety:

• Determine how many refills will be approved between patient examinations, and provide this information to the patient with the first order for the medication.
• Develop a protocol stating that requests for refills will be accepted only during regular office hours—never on weekends.
• Establish a protocol for covering physicians stating that they must not refill any prescriptions for your patients and that they should refer patients to the nearest ER for pain medications consisting of only a sufficient dosage to last until Monday when the office opens again.
• Train and educate all office personnel to use the rules established for refills. This will ensure consistency by all.
• Make no exceptions to the rules you develop.

Herbal Therapies
The average patient does not recognize herbal therapies as medications. The use of herbs might, however, interfere or interact with the medications that you prescribe. Unless you have knowledge of herbal use, your patients could suffer an unusual reaction or perhaps not benefit from your prescribed medication. Herbs and herbal therapies are enjoying a surge in popularity and must be taken into consideration by health care providers.

Begin by revising your initial patient intake information to ask what items the patient buys over the counter in the drugstore or supermarket. Be prepared to provide patient education materials on herbal uses and how they might interfere with prescribed medications. As with all medications taken by the patient, maintain information on the patient’s use of herbs in an accessible location in the medical record.

Sample Drugs
Sample drugs are a benefit for many patients, but they bring additional responsibilities for the provider. Sample drugs are useful if the provider is “trying out” a new drug to measure its effectiveness for a particular patient in lieu of ordering a full prescription at a very real cost. Samples are also useful for patients who do not have medication insurance coverage, who would not otherwise be able to purchase a prescription. To decrease your sample drug liability:

• Keep samples in a locked area that is inaccessible to patients. Make your drug representatives responsible for stocking the area and for removing any outdated drugs. Each representative should be permitted to touch only his or her own products.
• Keep a use log with the name of the drug, the patient name, the date, the dosage, the amount, and the lot number.
• Document the medical record with the drug name, the dose, the amount, the frequency, and the duration.

Diagnostic Workups
Among the many aspects of diagnosing, the failures are the key factors that work against patient safety—failure to be thorough, failure to order testing adequately, failure to listen properly to the patient’s symptoms, failure to follow, failure to diagnose, and failure to treat in a timely manner. Here are a few ways to protect your patients:

Gender
Although some diseases are known to affect a particular gender, there are now overlaps in certain health problems. Focus on the symptoms of disease regardless of gender. Use all of your senses when examining the patient.

The tests that you order may give you the satisfaction of a correct diagnosis or the knowledge that more testing is necessary. In either scenario, there is one mandatory rule: If a test is ordered, the results must be known and acted on. Otherwise, why order the test?

Follow-Up
Loss prevention measures for patient safety include establishing an office alert for any test, x-ray, or consult ordered so that staff can watch for results. The results can then be brought to the attention of the physician, who should initial the report and take the next step of communicating with the patient.

Physician orders are directly linked to the follow-up process. Responsibility for any and all follow-up rests with the physician and the office staff. The most reliable method for ensuring that nothing falls through your system is to develop a process for dealing with physician orders. Whether the orders are for tests or a next visit, your office staff should be able to track every order.

Patient safety can best be achieved with a tickler file. The system, which can be an electronic diary or a manually generated log, should keep the patient at the forefront until adequate follow-up is accomplished.

Document the Record
Documentation is vital. If your records are electronic, dictation will suffice. If they are manually driven, it is the responsibility of the person completing the task to provide the documentation. Remember: A task not documented is a task not done.

Patient Education
Patient education will enhance nearly every segment in this category of diagnosing. When the patient is fully aware and understands orders, the use of medications, and the necessity for follow-up, a giant step has been taken toward an excellent outcome. Patients who are well educated in the medical arena are more compliant and cooperative.

Summary

None of the elements covered in this article are new or earthshaking. Loss prevention for patient safety is really just reasonableness and common sense. By applying a generous dose of each, you can fine-tune your systems, enhance your practice, and achieve a measurable and consistent quality of care for your patients.