What’s New in the Patient Safety World

October 2013

New AHRQ Toolkit:

Improving Your Office Testing Process

AHRQ has just put out a new toolkit “Improving Your Office Testing Process”, aimed at helping offices track and follow up on tests ordered during office visits. Failure to follow up on test results is one of our most frequent topics and one of the most frequent causes for malpractice claims in outpatient medicine.

The toolkit provides step-by-step instructions on how to evaluate your office processes for tests and use rapid-cycle quality improvement techniques to make them safer and more reliable. It provides tools for assessing your testing practices and for planning your improvement project. For each step you map out it asks practical questions like who usually performs this step and who does it if that person is absent. It explains how to use a scoring tool to identify those areas most in need of improvement.

In addition, there is a patient handout and tools for assessing office readiness and patient engagement, and tools for chart audits and electronic record evaluations.

Gurdev Singh, BScEngg, MScEng PhD, Co-Director of the University of Buffalo Patient Safety Research Center and a coauthor of the AHRQ Toolkit notes “it is a proactive tool that empowers stakeholders at the point of care. It helps create teams that inculcate mutual respect, trust, collaboration and cooperation that leads to prioritization of hazards in the system and design of feasible interventions to reduce harm to all. As each setting is unique the tool is adaptable to fit its needs. The most important feature is that it promotes bottom-up approach designed to educate, engage and empower providers and patients with a mission to create high reliability organization.” 

We think most offices and outpatient clinics will find this toolkit easy to use and very valuable in improving one of the most important facets of ambulatory medicine.

See also our other columns on communicating significant results:

• Patient Safety Tip of the Week May 1, 2007 “The Missed Cancer”
• Patient Safety Tip of the Week February 12, 2008 “More on Tracking Test Results”
• Patient Safety Tip of the Week October 13, 2009 “Slipping Through the Cracks”
• What’s New in the Patient Safety World July 2009 “Failure to Inform Patients of Clinically Significant Outpatient Test Results
• Patient Safety Tip of the Week March 9, 2010 “Communication of Urgent or Unexpected Radiology Findings”
• Patient Safety Tip of the Week March 1, 2011 “Tests Pending at Discharge”
• Patient Safety Tip of the Week August 21, 2012 “More on Missed Followup of Tests in Hospital”

Some of our other columns on errors related to laboratory studies:

• October 9, 2007 “Errors in the Laboratory“
• November 16, 2010 “Lost Lab Specimens”
• October 11, 2011 “LEAN in the Lab”
• March 6, 2012 ““Lab” Error”
• April 2012 “Specimen Labeling Errors”
• January 22, 2013 “You Don’t Know What You Don’t Know”

References:

AHRQ Toolkit. Improving Your Office Testing Process. A Toolkit for Rapid-Cycle Patient Safety and Quality Improvement. AHRQ 2013

http://www.ahrq.gov/professionals/quality-patient-safety/quality-resources/tools/ambulatory-care/office-testing-toolkit/

patient handout

http://www.ahrq.gov/professionals/quality-patient-safety/quality-resources/tools/ambulatory-care/office-testing-toolkit/officetesting-toolkit8.html

office readiness survey

http://www.ahrq.gov/professionals/quality-patient-safety/quality-resources/tools/ambulatory-care/office-testing-toolkit/officetesting-toolkit4.html

patient engagement survey

http://www.ahrq.gov/professionals/quality-patient-safety/quality-resources/tools/ambulatory-care/office-testing-toolkit/officetesting-toolkit7.html

chart audit tool

http://www.ahrq.gov/professionals/quality-patient-safety/quality-resources/tools/ambulatory-care/office-testing-toolkit/officetesting-toolkit9.html

electronic record evaluation tool

http://www.ahrq.gov/professionals/quality-patient-safety/quality-resources/tools/ambulatory-care/office-testing-toolkit/officetesting-toolkit10.html

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