BMJ Open Quality (Jul 2024)

Patient safety in actioning and communicating blood test results in primary care: a UK wide audit using the Primary care Academic CollaboraTive (PACT)

  • ,
  • Jonathan Lucas,
  • Emmanuel Okenyi,
  • Jessica Watson,
  • Jane Wilcock,
  • Salman Waqar,
  • Alexandra Caulfield,
  • Penny F Whiting,
  • Alexander Burrell,
  • Emily Brown,
  • Clare Etherington,
  • Jonathan Stewart,
  • Chloe Evans,
  • Alice Howe,
  • Polly Duncan,
  • Samuel W D Merriel,
  • Ian Bennett-Britton,
  • Priya Deol,
  • Sam Hodgson,
  • Mohammed Bux,
  • Lakshmi Chandrasekaran,
  • Elizabeth Lovegrove,
  • Mohammed Subhi,
  • Efioanwan Damisa,
  • Alexandra Razumovskaya-Hough,
  • Ola Abdellatif,
  • Anthony Adaeze,
  • Josephine Adebayo-Begun Fosu,
  • Ifeoluwa Adebayo-Begun,
  • Edemanwan Etuk,
  • Tega Ayara,
  • Lucy Bradley,
  • Laura Black,
  • Georgina Butler,
  • Maeve Caviston,
  • Anna Ciolek,
  • Iain Cromarty,
  • Rik Fijten,
  • Sarita Gorolay Ben Goude,
  • Katy Horder,
  • Nicole Hurlin-Jones,
  • Scott Jamieson,
  • Ryan Jennison,
  • Neeta Khare,
  • Peter Lillie,
  • Imogen Llewellyn,
  • Shane McAnearney,
  • Andrzej Murawski,
  • Alison MacTavish,
  • Nkeiruka Sylvia Nwafor,
  • Akinwale Olakunde,
  • Ngozi Okeke,
  • Tanuka Palit,
  • Win Paing,
  • Lucie Parry,
  • Sarah Pocknell,
  • Alice Rhodes,
  • Edward Shattock,
  • Mutiat Salawu,
  • Hammad Shaikh,
  • Liesl Smith,
  • Gayle Thorpe,
  • Paul van den Bosch,
  • Catherine Vassallo,
  • Kimberly Thomas,
  • Emma Wyatt-Haines,
  • Oluwatoyin Yusuff

DOI
https://doi.org/10.1136/bmjoq-2023-002632
Journal volume & issue
Vol. 13, no. 3

Abstract

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Background Errors associated with failures in filing, actioning and communicating blood test results can lead to delayed and missed diagnoses and patient harm. This study aimed to audit how blood tests in primary care are filed, actioned and communicated in primary care, to identify areas for patient safety improvements.Methods UK primary care clinicians were recruited through the Primary Care Academic CollaboraTive (PACT). PACT members audited 50 recent sets of blood tests from their practice and retrospectively extracted data on blood test result coding, actioning and communication. PACT members received a practice report, showing their own results, benchmarked against other participating practices.Results PACT members from 57 general practices across all four UK nations collected data on 2572 patients who had blood tests in April 2021. In 89.9% (n=2311) they agreed with the initial clinician’s actioning of blood tests; 10.1% disagreed, either partially (7.1%) or fully (3.0%).In 44% of patients (n=1132) an action (eg, ‘make an appointment’) was specified by the filing clinician. This action was carried out in 89.7% (n=1015/1132) of cases; in 6.8% (n=77) the action was not carried out, in 3.5% (n=40) it was unclear. In the 117 cases where the test result had not been actioned 38% (n=45) were felt to be at low risk of harm, 1.7% (n=2) were at high risk of harm, 0.85% (n=1) came to harm.Overall, in 47% (n=1210) of patients there was no evidence in the electronic health records that results had been communicated. Out of 1176 patients with one or more abnormal results there was no evidence of test communication in 30.6% (n=360). There were large variations between practices in rates of actioning and communicating tests.Conclusion This research demonstrates variation in the way blood test results are actioned and communicated, with important patient safety implications.