Are we properly tracking tests results and referrals? 
Risk: Missed diagnosis of celiac disease. Three years after being tested for celiac disease, a delayed diagnosis is uncovered.

Am I sure my patient got the test I ordered? 
Risk: Misfiled results. Multiple providers fail to reconcile an outstanding imaging study due to inadequate test result management system.  

Is my specimen handling process reliable?
Risk: Mismanaged specimen. Patient suffers unnecessarily due to improper management of lab specimen obtained during a physician office visit.

Who is responsible for follow up?
Risk: Reconciled referral. Lack of follow up with patient due to inadequate office practice system to track record from specialist visits.

Is my patient’s history up to date?
Risk: Missing/dismissing information. Failure to appreciate history, signs, and symptoms of a patient’s critical illness.

Does my patient understand why I ordered this test?
Risk: Failure to follow up on a new finding. Patient skipped a recommended echocardiogram, then died suddenly of heart failure.

Are we prepared to triage this patient call?
Risk: Patient is in need of more immediate care than is conveyed over the phone.

Should I use a decision support tool?
Risk: Failure to diagnose. Inadequate management of a patient-detected breast lump.

Is this procedure what the patient consented to?
Risk: Failure to obtain a complete informed consent for procedure provided. The patient’s original referral procedure was intentionally changed from right to left and informed consent was not signed.

Did the specialist change the treatment plan?
Risk: Miscommunication about anticoagulation. PCP was unaware the patient’s cardiologist had discontinued her Coumadin