Critical lab result policy cuts hospital's med errors
Critical lab result policy cuts hospital's med errors
A system that requires calling physicians directly with critical lab test results can greatly improve patient safety, according to a hospital team that has had such a policy in place for years. Many hospitals will have to develop a whole new way of communicating test results, they say, but the effort is worthwhile.
Mount Auburn Hospital in Cambridge, MA, a teaching hospital of Harvard Medical School, has used such a system for 15 years, and now other hospitals are catching on to the idea, says Susan A. Abookire, MD, MPH, chair of quality and safety at Mount Auburn. The idea itself is simple — call the doctor directly when the test results are critical — but implementing it can be a challenge.
Gayla Jackson, RN, BSN, a nurse manager at Mount Auburn who has been a key leader in the patient safety initiative, says the hospital was spurred to improve its critical test reporting by an adverse event at the hospital that was traced back to a lapse in communication. Jackson witnessed the tragic result and realized the hospital needed a better system.
"Afterward, with everyone looking at each other and saying, 'What happened? What happened?' we realized it happened because we didn't have a good system in place," Jackson says. "It was over 20 years ago, but we don't forget that incident. It showed us how important this is."
Abookire points out that it still is not the norm for hospitals to have firm, detailed policies on communicating critical test results. Too often, she says, clinicians rely on written messages, voice mail, or someone's promise to pass on the information to the right person. "There are people whose lives have been lost because of a Post-It note falling off a piece of paper," Abookire says.
Little structure in previous system
Before Mount Auburn implemented the current system, getting critical test results to the physician was more haphazard. The laboratory called the unit secretary with a critical test result, and the secretary wrote down the critical result in order to hand it off to the registered nurse on the unit, who would then identify and page the ordering physician. When the physician called, the nurse would pass on the test results.
"Clearly the potential for error was enormous," Abookire says. "Reliability, hand-offs, turnaround time, and receipt and acknowledgment of the critical test result are all crucial elements of our process that had to be examined."
Twenty years ago, the hospital's initial attempt to improve the communication of critical test results started in its laboratory, where staff began calling all the defined critical test results to the ordering physician. But even with a popular decision to do this, the staff found that the volume of calls from the lab to the ordering physician was too large and too time-consuming to be realistic.
To improve upon the original idea, the lab began calling for "first-time criticals" only and not subsequent criticals. This change brought the number of calls down to a reasonable number. Jackson says the lab staff make an average of 600 calls per month for critical results on inpatients. That number works out to about 20 calls every 24 hours or one or two calls per tech on an average day, she says.
As the policy continued to evolve, Mount Auburn added the verification "read-back" by the physician receiving the critical result. This acknowledgment is documented with the result in the hospital computer system and includes the physician's name, beeper number, and the date and time the result was acknowledged. Critical results are never released to an answering service or voice mail. Instead, the lab requests that the doctor call back immediately.
Must be able to reach physician
Of course, the system relies on being able to contact the physician directly. Jackson says the hospital's ability to identify and locate the ordering physician is made possible by the telecommunications department, which is responsible for maintaining all physician call schedules, beeper numbers, and private practice numbers.
If the ordering physician is not found, the staff member calls a resident, then an attending, and lastly the pathologist on call and present in the hospital, Jackson says. Attempts to call the physician have been shortened from 30-minute to 10-minute intervals, for a total of three calls. Each physician receives calls only for his or her own patients' critical results, so the doctor doesn't receive an excess of phone calls.
"But still, when we first introduced the idea, we had physicians say they're too busy to be called directly. My reaction was, 'I'm glad you're not my physician,'" Jackson says. "Now that they see the volume is not excessive, we have good support."
Physician education is key
With the success of the lab policy, the process for reporting critical test results was expanded to other departments at Mount Auburn. Abookire says the standard has been systematically implemented in radiology, cardiology, and now across the discharge process.
Instituting this type of policy requires a culture change, Abookire says. Even with clearly defined policies and procedures, the whole plan can fall apart if the doctor does not accept the call, she says. The Mount Auburn team spent a lot of time meeting with physician leaders to show that they would be called only when the test results are critical and he or she must hear them immediately.
"When the physician is backed up and has 10 patients in the waiting room and he's in with a patient, it's very tempting for him to say, 'Just take a message,'" Abookire says. "But that defeats the whole purpose of the system, so we have to educate the physicians about how important this is, that these are the kind of results they want to know right away, the kind that would make them jump out of bed at 3 a.m. and rush to the hospital."
Sources
For more information on reporting critical results, contact:
- Susan A. Abookire, MD, MPH, Chair of Quality and Safety, Mount Auburn Hospital, 330 Mount Auburn St., Cambridge, MA 02138. Telephone: (617) 575-8603.
- Gayla Jackson, RN, BSN, Nurse Manager, Mount Auburn Hospital, 330 Mount Auburn St., Cambridge, MA 02138. Telephone: (617) 492-3500.
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