Reporting test results requires vigilance
Reporting test results requires vigilance
The reporting of critical test results and lab values is the kind of process that makes a risk manager nervous if you think about it too much. How do you really know if your organization is reporting test results promptly, efficiently, and effectively, every single time? After all, getting it right most of the time isn't good enough. Drop the ball just once, and a patient could suffer terribly, not to mention the resulting lawsuit.
All test results should be reported properly, of course, but it is the critical test results that pose the biggest risk management nightmare. A critical test result is defined as one that is sufficiently abnormal that the patient is potentially at risk of sudden death or immediate harm, explains David S. Wilkinson, MD, PhD, FCAP, a pathologist with the Virginia Commonwealth University (VCU) Health System in Richmond, chair of the Department of Pathology at VCU, and chair of the College of American Pathologists' Quality Practices Committee.
For risk managers, Wilkinson says a key step is for the organization to define its list of critical test results. Not every single test result can be handled as if it is of the utmost importance Wilkinson's lab produces results on almost 3,000 different tests so your organization must know which ones should be considered critical. That means not just which test, but which test results, he notes. In some cases, the results of a particular test will always be of critical importance. But in other cases, the results of the test will be critical only if they fall sufficiently outside the normal parameters.
"The list will be different for each institution based on the type of care you provide and the patients you see, but you need to know which tests and results to watch out for. Get all the definitions on the table and make sure everyone understands what you mean when you say critical test results," he says. "Then, it is a matter of having the right policies and procedures in place so that the workers, the medical laboratory technicians, or the licensed health care providers who may be receiving these critical results or the physicians themselves understand what to expect."
Track metrics to measure success
That is a part of the process where risk managers can play a significant role, Wilkinson suggests. The risk manager can facilitate the communication between the parties and oversee the policies and procedures that must be followed when a critical test result is in play.
Tracking metrics regarding critical test results reporting also is important, Wilkinson says. There is no way to know how well you report results if you don't follow the data, he says. Risk managers should be directly involved in measuring the metrics and analyzing those data, then using the information to tweak the reporting policies and procedures.
Wilkinson notes that there are several ways the process of reporting critical test results can go wrong. Simply failing to pass on the information to the nurse or physician is only the most obvious way the process can fail; it actually is not the most common error. Reporting incorrect information because the patient or specimen was misidentified actually is a much more common way a critical result is miscommunicated, Wilkinson says.
"Probably by at least a factor of 10, that's far more common than other types of failure," he says. "You just got the wrong blood in the wrong tube somehow, and so the results you're reporting are not accurate for that patient. That is much more common than the situation in which all the actual testing went according to plan in the laboratory and then somehow the result does not get communicated properly after that."
Elizabeth A. Wagar, MD, FCA, clinical laboratory manager at the University of California Los Angeles Clinical Laboratories with the David Geffen School of Medicine, says the most recent data on critical value reporting indicate that about 1% of specimens are mislabeled, and some of those results could involve critical values.
That means that any effort to ensure reporting of critical test results should encompass that potential error also, she says. The actual reporting process in the laboratory also must accommodate the real-world difficulty of getting a doctor on the phone, she says. Laboratories have policies and procedures for calling physicians or nurses to report critical values, and they have computer programs to facilitate this; but research indicates that between 0.1% and 0.3% of those calls are not completed for technical reasons, or the person just cannot be reached, Wagar says.
"So, things do just fall through the cracks sometimes," she says. "There are scenarios where that can be very important."
Wagar's research has suggested that there are two practices that can improve the success rate for reporting critical values:
Laboratories that report critical values only to health care professionals not a receptionist or an answering service, for instance have a better record of successful reporting.
Critical value reporting is more consistent and effective when the laboratory does not make many exceptions for individual physicians when defining critical values.
Assuming the specimen was collected and tested properly, then the next concern should be whether the critical result was communicated properly. To make monitoring of that process possible, the computer system in Wilkinson's lab requires that the technologist attach a comment detailing the reporting process to the result in the clinical laboratory information system. Then the lab managers can periodically query the databases to compile all critical test results (as defined at VCU) and determine if there is a comment documenting that the technologist called that test result in to the caregiver.
"We check on a daily basis. Through a typical month, we may have a couple thousand critical results, and there may be one or two where that communication was not documented," he says. "Sometimes, we find out that the technologist did call the result in but didn't document it in the system. Occasionally, just because things are busy and you're depending on individuals, the result is just not communicated. Monitoring that on a daily basis minimizes the potential for harm."
Auditing the process is crucial to ensuring the proper reporting of critical test results, Wilkinson stresses. No matter how good your policies and procedures are, routine auditing will reveal room for improvement, he says.
Formalize reporting process
Wilkinson also points out that reporting the critical test result to a physician is not always as simple as it sounds. Calling the doctor directly is the best option, but that can be a challenge when the physician who ordered the test is now off duty or has transferred care to another doctor. In many cases, the lab must report the result to a nurse, which creates a longer chain of communication, as the nurse then must report the result to a physician.
"I'd see that as an area where risk managers can have a lot of influence," Wilkinson says. "What happens in the lab is something that I can control, but what happens with that critical result once it is reported to the floor has to be directed by policies and procedures in the organization."
Accurate reception of the results is another concern. A common method for ensuring accurate communication is for the lab to use a standardized format for the report that includes stating the patient's name, medical record number, the test, the result, and the statement. "This is a critical value." The reporter then asks the receiver to read back the information. The caregiver reads back all of the information, including the patient's name and other identifiers, to ensure accuracy. Some organizations require the receiver to state "I understand this is a critical value" or words to that effect.
Properly identifying the patient is of utmost importance, Wilkinson notes. The exchange must include at least two patient identifiers, such as the name and medical record number. Risk managers should never allow a report with just the patient's name, or even worse, a casual reference to "that potassium level you wanted." Formalization of the reporting process is extremely important, Wilkinson says.
Wagar notes that risk management can be quite helpful to the laboratory manager when it comes to ensuring proper reporting and in the investigation of problems. She encourages risk managers to develop a personal relationship with the lab manager so that the two can collaborate on patient safety.
Wagar also points out that in many organizations, the risk manager overlooks the resources in the laboratory when investigating adverse events. Laboratories have detailed record-keeping systems that indicate how and when results were communicated, which often can be useful in a risk manager's investigation, she says.
"When I have looked into situations in which the reporting of critical values might have led to problems with patient management, I have worked as partners with risk management to do the investigation," she says. "They can go to the individual clinical services, and we can work together to find out what the issue was. I also highly recommend that the lab manager and the risk manager both be on the quality committee or the patient safety committee so that they can work together on these concerns."
Sources
For more information on reporting critical test results, contact:
David S. Wilkinson, MD, PhD, FCAP, Chair, Department of Pathology, VCU Health System, Richmond, VA. Telephone: (804) 828-0183.
Elizabeth A. Wagar, MD, FCA, Clinical Laboratory Manager, University of California Los Angeles Clinical Laboratories, David Geffen School of Medicine. Telephone: (310) 267-8109. E-mail: [email protected].
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