Table 2

The top 15 most frequently occurring hazards identified during CRSA visits to general practices by MPS (n=647)

NoHazard categorynPer cent
1Inadequate process for matching test requests and results received35054.1
2Inadequate tracking process to check patients attend on request following abnormal results being received34052.5
3Informing patients of some test results before all results are received19530.1
4System reliance on patients contacting practice for test results16625.7
5Test results not being forwarded to covering GPs in a timely manner (inadequate ‘buddy system’, ie, a clinical colleague covers the work of a colleague on annual leave or sick leave, etc)9414.5
6Family members and ‘Third Party’ requests for test results9114.1
7Communicating incorrect results8012.3
8Ambiguous and/or unclear instructions given to frontline administrators by GPs to communicate to patients7812.1
9Front-line administrators asked by patients for test results and to provide addition information/interpretation7511.6
10Failing to ‘action’ clinically abnormal results received6910.7
11Lack of system standardisation—variation and inconsistency in how GPs review and action test results619.4
12Lack of a formal protocol describing the overall system588.9
13No documented record of tests requested to ensure that all tests and results have been reported on568.7
14Test results not forwarded to the requesting GP/GPs reporting on test results ordered by a colleague548.3
15Desired action not carried out, that is, due to difficulty contacting the patient or task not being completed497.6
  • CRSA, clinical risk self-assessment; GP, general practitioner; MAS, Medical Protection Society.