Risk Management: 
Communicating Critical Test Results, Part II
Page 2

Communicating and Acting on Critical Test Results: Part of a Process   While at first it may appear deceptively simple, health care clinicians need to see CTRs in the “Big Picture” – and understand that ordering tests, reporting results and values, and then acting on those results are steps in a complex process of medical care.  In part 1 of this Risk Review article, we mentioned the work of the Massachusetts Coalition. (a group of MA hospitals that collaborated in a patient safety initiative to try to improve the ability to communicate critical test results)  The Coalition defined CTRs as values/interpretations for which delays in reporting can result in serious adverse outcomes for patients.   One product of the Coalition’s work was development of a set of “Safe Practice Recommendations” to promote successful communication of CTRs.[1] These recommendations address the following *nine issues:   Identify who should receive the results Identify who should receive the results when the ordering provider is not available Define what test results require timely and reliable communication Identify when test results should be actively reported to the ordering provider and establish explicit time frames for this process Identify how to notify the responsible providers Establish a shared policy for uniform communication of all types of test results (laboratory, cardiology, radiology and other diagnostic tests) to all recipients Design reliability into the system Support and maintain systems Support infrastructure development   * The need to break out these recommendations into nine sub-parts just underscores the complexity of this problem.   With respect to identifying critical test values, the Coalition found little consistency across institutions and wide variations in definitions, terminology and test types.  To help resolve this, the Coalition developed a “Starter Set” of test results that organizations could refine and customize. [2]   Causes of Failure to Follow-up Abnormal Test Results  Abnormal test results need to be communicated quickly to a responsible caregiver so that action can be taken – additional tests, diagnosis, therapy begun, etc.  Nevertheless, failure to recognize and act on abnormal test results seems to be a common occurrence in healthcare.  In one study designed to discover the underlying reasons for this problem, the researchers conducted a structured review of the medical literature, abstracting 25 original research studies that addressed the frequency and/or reasons why providers do not follow up on abnormal test results.[3] Through their analysis, the authors identified the following causes for why a provider did not take action on an abnormal test result:   1)      Test result was not correctly communicated to responsible provider; 2)      Result was communicated but never received/reviewed by provider; 3)      Result was reviewed but no action was recommended; 4)      Action was recommended but not carried out.   Discussion and Conclusions: The authors of this study developed an operational model for analyzing the processes of care that result from ordering a test. They concluded that their findings support the growing evidence that failure to act on abnormal test results is a common medical error, with potentially serious consequences.  For the individual patient, it can mean loss of opportunity to begin treatment. For providers and health systems, the outcome can be legal liability, loss of patient trust and unnecessary costs (if test is performed but not reviewed).  While acknowledging the complexity of this problem, the authors suggested that one potentially effective solution might be direct patient notification (by mail or phone.)  Also, providers should create back-up systems to ensure that patients are notified of their test results.   JCAHO National Patient Safety Goals  The impact of communication errors and/or breakdowns on patient care outcomes and patient safety can be so clinically significant that organizations such as the JCAHO have developed goals to encourage healthcare organizations to improve communication.   In 2002, the JCAHO approved its first set of six National Patient Safety Goals (“NPSG”), with 11 related specific implementation requirements for improving the safety of patient care in health care organizations. All JCAHO accredited health care organizations are surveyed for implementation of these goals and/or acceptable alternatives, appropriate to the services provided.  In 2004, the JCAHO began developing program-specific NPSGs for each of its accreditation and certified programs.  The NPSG are reviewed and updated annually.   [1] Getting Results: Reliably Communicating and Acting on Test Results, 2006 by the Joint Commission on Accreditation of Healthcare Organizations; Joint Commission Resources, Inc.; Chapter 7:  Communicating Critical Test Results: Safe Practice Recommendations; D. Hanna, P. Griswold, L. Leape, D. W. Bates. Table 1 (pages 57-63) [2] Same as above - Getting Results; Appendix 1 (pages 65-67). [3] Getting Results: Reliably Communicating and Acting on Test Results, 2006 by the Joint Commission on Accreditation of Healthcare Organizations; Joint Commission Resources, Inc.; Chapter 6:  Failure to Recognize and Act on Abnormal Test Results; P. Cram, G.E. Rosentahl, R. Ohsfeldt, R.B. Wallace, J. Schlechte, G.D. Schiff (pages 45-53)