Mr B, a 58 year-old, visited his GP with various health concerns. Dr G decided to undertake a series of blood tests, including a PSA (prostate specific antigen) test after discussing with Mr B.

Mr B made an appointment to have the blood tests taken at the practice. He attended the appointment and had a number of samples taken by the practice nurse. However, she inadvertently failed to send a sample for the PSA test as requested.

Mr B contacted the practice, as directed, to obtain his test results and was informed that they were all normal. He wrongly assumed that the PSA result was also normal. Dr G failed to notice that the PSA test was not included in the list of tests that he reviewed, as he relied on the computer system to ‘flag up’ any abnormal results.

Mr B did not return to see Dr G for 12 months. Dr G then discovered that the PSA test had not been done previously and was very concerned about the patient and made an urgent specialist referral due to the severity of his symptoms. Unfortunately, Mr B was diagnosed with prostate cancer.

Mr B then decided to make a claim against Dr G for clinical negligence, as he felt that the diagnosis of cancer was delayed leading to a more invasive treatment for the cancer, which could have been avoided had the diagnosis been made at an earlier stage.

This scenario is fictional but based on real Medical Protection cases.

Managing test results

The test result management system in general practice is complex, involving many members of the practice team. It is a system vulnerable to human error, with significant potential for mistakes.

We looked at 50 randomly selected claims from general practices over a three-year period – January 2014 to December 2016 – and found evidence of suboptimal management of test results.

Our review looked at the factors that appeared to contribute to an adverse event across two domains:

• High level system domain (practice system interactions)¹

• Contributory factors domain, by using a framework for patient safety incident investigation.

High level system domain (practice system interactions)

Each case was reviewed to identify errors at the four stages in the management of test results:

• Pre-analytical stage (test ordering stage)
• Specimen processing stage (specimen being sent to the lab)
• Post-analytical test stage (test results review and action stage)
• Communication outcome issue (communicating test results to the patient).

There were 85 system errors identified across the four stages. However, there were no errors identified in the specimen processing stage, as shown in chart 1.

Test result system interactions errors

Pre-analytic test stage

15% of the systems errors identified involved the pre-analytic test stage. These were errors about ordering a specific test:

• Failure to order the required test.
• Test not done as part of annual screening.
• Failure to follow-up or order blood tests requested by secondary care.

Specimen processing stage

The specimens were successfully sent to the laboratory, and no errors were found at this stage. Incidents such as broken containers/package or lost specimens while in transit are possible errors in a different scenario.

Post-analytic test stage

37% of the systems errors identified involved the post-analytic test stage, such as:

• Failure to forward the test result to the appropriate clinician.
• Lack of a ‘buddy system’ – if a GP is on leave, the practice administrator should assign the management of test results to another GP. Even if this is done, there may be delays.
• Not acting on results that require action.
• Result filed accidentally without being reviewed.
• Suboptimal management of multiple results for a single patient – patient was informed that their test results were normal, where not all of their test results were back.

Communication outcome issue

48% of the 50 Medical Protection cases reviewed involved patient contact issues and failure to inform the patient of the abnormal test result. Often, it had been documented that the GP intended to advise the patient to make an appointment. But for various reasons, the GP did not convey this to the patient and therefore the abnormal result was not acted on. Such communication errors frequently resulted in a failure or delay to refer the patient for specialist treatment.