Ensuring patient safety: Are your practice’s processes letting you down?


Unless you are in a solo practice, there will be a number of staff involved in running the business and delivering healthcare. Sound systems and processes are the main stays of ensuring safety and efficiency, so any gaps or failures in processes can have serious implications for the doctor, who is rarely involved in the lead-up to a consultation.

Avant received 2,443 calls from practices in 2018 and many more from doctors seeking advice on situations involving practice staff. Situations such as the one below show how simple mistakes can lead to serious harm and legal action.

Patient identity confusion

A 62-year-old Italian female patient was called from the waiting room using her first name only. The surgeon opened the patient’s electronic file and made notes about the patient’s reason for attendance, which was a follow up appointment after scar excision procedure. Antibiotics were prescribed, noting no known allergies or current medications.

After the patient arrived with a prescription at the pharmacy, the pharmacist phoned the surgeon to inform them the patient was allergic to the prescribed antibiotic and her address and contact details were incorrect.

Upon investigation, it was discovered the incorrect patient had been entered into the electronic appointment system by reception staff when the appointment was booked. The surgeon had then opened the patient file from the appointment schedule.

The patient had not been adequately identified by staff at any stage throughout their visit to the practice. Thankfully, the error was picked up before any harm was done, but the outcome could have been significantly different both for the patient and the practice.

Preventative processes

Having sufficiently robust processes in place which are followed by all practice staff is essential.

  • Policies and procedures need to be easily accessible and searchable online to ensure all staff are on the same page. In the above situation, having a policy in place which requires identification of patients using one of three approved identifiers, would have helped.
  • Have a streamlined and efficient induction process to make on-boarding new staff simple and consistent. Induction protocols with training and accountability sign-off ensure staff treat the policies seriously.
  • Reinforce staff understanding on a regular basis using comprehensive training modules in areas such as patient health records, and privacy and confidentiality.

Support team members have an important role to play in delivering safe healthcare. Training and compliance currency need to be prioritised so they know they are doing things correctly.

Errors made by support staff can contribute to poor patient outcomes, complaints or legal actions against the practice. Not only can this damage the practice’s reputation, it is not likely to be covered by the doctors’ personal liability insurance.