Complying with JCAHO’s read-back requirement

Take steps to reduce communication errors

Do all staff at your organization know what constitutes a "critical test result?" If not, this could cause you problems during your next survey.

The Joint Commission on Accreditation of Healthcare Organization’s 2004 National Patient Safety Goals include a requirement to eliminate communications errors, failures, and delays, with a recommendation that all critical test results be reported verbally or by telephone and read back.

"With the read-back requirement, the Joint Commission is trying to reduce or eliminate error caused by oral miscommunication of a medication to be administered and assure that critical test results have appropriate actions taken to protect the patient," says Leisa Oglesby, assistant hospital administrator of quality services at Louisiana State University Health Sciences Center in Shreveport.

Here are some effective ways to comply:

• Define "critical" test results. According to the Joint Commission, the term "critical test results" refers to all diagnostic tests including imaging studies, electrocardiograms, and laboratory tests. However, the Joint Commission expects each organization to define critical test results and will measure compliance as defined by the organization’s policy.

"Each organization will need to sort out what is life-threatening and requires immediate action from those results that are important but could be reported some time later," says James H. Nichols, PhD, DABCC, FACB, director of clinical chemistry at Baystate Health System in Springfield, MA. The organization has a critical values policy approved by the chief of clinical pathology and the patient care policy and medical staff executive committees, he says. "Any changes have to go through this multilevel approval process." The policy lists all the results that meet the criteria for critical values, based on the test, age, sex, and other conditions.

Each diagnostic department has defined criteria for which test results are considered "critical" within their area, says Oglesby. "For instance, an echocardiogram may be different from a lab, and a chest X-ray may be different from a gastrointestinal X-ray," she says.

• Decrease the number of handoffs. At Baystate, a process is being piloted to decrease the number of handoffs in the procedure for critical test results. Previously, whoever answered the phone on the nursing unit would communicate with the nurse in charge of the patient, who in turn would talk to the clinician about the test results. Now, the lab communicates directly with the nurse caring for the patient, who either acts based on preexisting orders or contacts a clinician who can act on the result.

"This has led to significant improvements in the time to clinical action," Nichols says. The time frame from the lab calling the result to when the physician takes clinical action was reduced by removing the middleman, he explains. "Previously, the ward clerk or secretary may have taken the result and then had to communicate it to the nurse or clinician, who could take medical action."

• Implement a read-back procedure. Baystate Health System’s read-back procedure requires the person accepting the result to state his or her name or ID number and read the test, value, and units back with the patient’s name to the lab tech on the phone. The lab tech then documents that "the value was called to____ by tech_____ @ time," and that "the value and patient’s name were verified by read back" as a comment in the result field of the lab report in the medical record.

The read-back procedure for nursing units is for the nurse accepting the verbal order to record and then read back the order in its entirety to the prescribing physician at the time the order is given, documenting that the order was read back. "The physician or designee shall be notified of all critical, life-threatening results within one hour via telephone," Oglesby explains.

The individual accepting the reporting of critical values must record and read back the critical value in its entirety to the reporting individual at the time the critical value is given and document that the critical value was read back.

The hospital’s clinics are notified by the diagnostic area of the critical value. The accepting staff must notify the physician within one hour and document in a clinic log and the medical record the date, time, staff member’s name receiving the result, the critical result, and actions taken as directed by the physician.

For diagnostic areas, technicians are required to keep a log documenting who the results were reported to and the time they were reported. For example, if a technician finds an abdominal aortic aneurysm on X-ray, the technician would notify the medical staff and document in a logbook that he or she talked with that physician, Oglesby says. "Also, the physicians in the diagnostic areas notify the patient’s attending physician to report the critical value. The diagnostic area physician documents in their dictated report the discussion with the attending physician," she says.

• Have a process to notify patients. When a patient has a critical test result, not only does the technician who is doing the interpretation have an obligation to notify the physician, but the hospital has an obligation to notify that patient, Oglesby says. "That is the other piece, that when you have a critical test result, the patient is notified and appropriate action is taken."

A policy is in place to notify patients of any test result that could result in a life-threatening risk to that patient. "We have an emergent procedure where the sheriff’s office is notified to go to the person’s home if it is potentially life-threatening, such as a potassium level indicating a severe electrolyte imbalance," Oglesby explains.

• Measure compliance. Currently, compliance is measured by pulling all critical results called and reviewing manually, Nichols says. "We’re looking into a system that would require the technician to enter the verified by read back’ comment or the result cannot be verified," he reports.

The organization’s laboratory information system could be programmed to remind the technician to make the call by requiring the comment to be completed. Then after the result is reported, the system would check to be sure that the comment was attached, Nichols explains. "This would mandate that the action takes place actively, rather than having the comment as a passive supplement to the result," he says.

He notes that there are newer "middleware" solutions, which are software data managers that sit between the analyzer and the laboratory information system. These can sort data, run statistics, and perform rules-based algorithms on data before sending it to the system. "For those laboratory information systems that can’t mandate read-back comments, middleware could be an alternative means of reminding the tech by flagging the result if they attempt to finalize it without the comment," Nichols points out.

Compliance is measured through chart audits as well as observation and mock surveys, says Oglesby. "If we’re up on the floor looking at environment-of-care issues and someone takes a verbal order or calls with a critical test result, we document that we observed that while on the floor, and whether they did it right or not."

If the proper procedure is not followed, the observers stop to educate staff. Recently, chart audits revealed that the read-back procedure was not always being done. "Staff were not calling the requested physicians with the critical lab or X-ray results," she says. "We have had to educate the staff involved, with inservices, staff meetings, and chart audits completed for physician peer review."

[For more information, contact:

James H. Nichols, PhD, DABCC, FACB, Director, Clinical Chemistry, Baystate Health System, 759 Chestnut St., Springfield, MA 01199. Phone: (413) 794-1206. Fax: (413) 794-5893. E-mail:

Leisa Oglesby, Assistant Hospital Administrator of Quality Services, Louisiana State University Health Sciences Center-Shreveport, 1541 Kings Highway, Shreveport, LA 71130. Phone: (318) 675-5030. Fax: (318) 675-4646. E-mail

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