The Doctor’s Company sells medical malpractice insurance to doctors. In 2010, it conducted 525 patient safety site surveys. The surveys were conducted across a range of practice environments around the country—from small office practices to large integrated delivery systems, hospitals, and outpatient facilities, such as surgery centers.
The survey found that in the 15 categories it surveyed, medical record documentation was the category with the most frequent patient safety/risk management issues. A total of 266 surveys—more than half of the 525 site surveys—had at least one issue related to this category. Top findings within this category included the failure to document allergy status in the same location in each record and the lack of a problem list or a list of current medications.
The research also disclosed that two combined categories—lab tests/referrals and scheduling/follow-up—came a close second with issues in 234 of the surveys. Although the categories are individually ranked fourth and fifth,searchers determined that the they are so closely related that a finding in one typically leads to a finding in the other.