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Mitigating the risks involved in DNAs

Practices should have a system in place to review patients who fail to attend or cancel appointments initiated by the practice, explains MDDUS senior risk adviser Liz Price.

When the practice asks the patient to attend, the level of urgency should be made clear to the patient and staff (Picture: iStock)
When the practice asks the patient to attend, the level of urgency should be made clear to the patient and staff (Picture: iStock)

In the midst of a busy surgery, particularly one that is running behind, many clinicians describe feeling a sense of relief when a patient doesn’t turn up for their booked appointment.

Whilst you might be tempted to use the extra time to grab a much-needed coffee, catch up with some emails or just plain catch up, it is important to be aware that not attending to patients defaulting on their appointments can have serious consequences for patients and, by their omission, practices themselves.

Risks for practices

Picture this scenario: one of your patients (an infrequent attender) recently had a consultation at which you arranged to have some bloods taken. The results return to the practice and are clinically significant. You initiate an action for the reception team to contact the patient, to ask them to come in for an appointment with you.

At this stage, do you think any more about the patient or would you know if the patient forgot about their appointment or, if their symptoms had subsided, decided a follow-up appointment was not necessary?

Let’s assume that the receptionist has informed the patient that they have been asked to come in and that an appointment was arranged at the time of the telephone call. Most practice systems would not generate an alert if this patient then cancelled the appointment.

Because of this, it is important that the urgency of any need to review a patient is communicated to the receptionist AND on to the patient as necessary. Even if the patient feels better, there will continue to be an underlying health risk which requires action.

All practice systems flag that a patient has not attended for a booked appointment. In any subsequent investigation of a missed or delayed diagnosis, it could be argued that the practice missed an opportunity, and it would have been safer if they had a system in place to maximise the effectiveness of this flag.

How to mitigate the risks

Here are some risk mitigation actions practices should consider so that a robust system is in place to flag any required actions if a patient cancels or DNAs for their appointment.

Communicate urgency/need
When a patient is contacted by the practice to book a return or review appointment, the level or urgency or need should be made clear both in-house with non-clinical staff and with the patient. Does the patient need a routine appointment or do they need to be seen that day?

What are the rules of escalation should the receptionist not be able to contact the patient or persuade them that follow up is necessary?

Create a flag
When an appointment is initiated by the patient, it is good practice to record the reason for the appointment in the patient’s appointment slot, with their consent. This can be useful to help establish the level of urgency and to ensure the patient is seen by the most appropriate clinician.

When the appointment is initiated by the practice, it should also be noted who instigated the appointment as this can impact of the subsequent actions of the practice. For example, if the patient cancels an appointment that they initiated then it is likely no further action is needed. But for appointments initiated by the practice that are cancelled by the patient, it may reduce risk if the clinician is able to assess whether further follow-up action is required.

These details ensure the clinician seeing the patient straight away is properly briefed – particularly as the patient could be asked to see a practice nurse or HCA.

Attend to DNAs
When a patient does not attend for their appointment, take a few seconds to check the appointment slot to see whether there are any workflow notes. In particular it should be considered that some vulnerable patients may need extra support or advice.

It could be that this simple system prompts a further (perhaps more successful) contact with the patient, thereby both avoiding exposure of the practice to risk and the patient to preventable harm.

Document all attempts to contact the patient
Finally, even with your best efforts to reduce risk, in the event of an adverse incident it is important to have clearly documented all attempts to contact the patient and the advice given to them about why it is important that they are followed up.

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