Table 2.

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

No	Hazard category	n	Per cent
1	Inadequate process for matching test requests and results received	350	54.1
2	Inadequate tracking process to check patients attend on request following abnormal results being received	340	52.5
3	Informing patients of some test results before all results are received	195	30.1
4	System reliance on patients contacting practice for test results	166	25.7
5	Test 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)	94	14.5
6	Family members and ‘Third Party’ requests for test results	91	14.1
7	Communicating incorrect results	80	12.3
8	Ambiguous and/or unclear instructions given to frontline administrators by GPs to communicate to patients	78	12.1
9	Front-line administrators asked by patients for test results and to provide addition information/interpretation	75	11.6
10	Failing to ‘action’ clinically abnormal results received	69	10.7
11	Lack of system standardisation—variation and inconsistency in how GPs review and action test results	61	9.4
12	Lack of a formal protocol describing the overall system	58	8.9
13	No documented record of tests requested to ensure that all tests and results have been reported on	56	8.7
14	Test results not forwarded to the requesting GP/GPs reporting on test results ordered by a colleague	54	8.3
15	Desired action not carried out, that is, due to difficulty contacting the patient or task not being completed	49	7.6

CRSA, clinical risk self-assessment; GP, general practitioner; MAS, Medical Protection Society.