Based on the examples discussed above, taken from real claims, we have illustrated how negative consequences can occur as a result of ineffective communication of CTRs. 

We suggest the following actions for hospitals:

·         Hospitals need to develop policies which clearly define roles and responsibilities and timing for notifying the appropriate responsible provider (often the attending, or PCP).  There also needs to be a back-up system, with clear identification of who get results when an ordering provider is not available, and when to use it.

·         Pay attention to and develop special procedures for situations where delays typically occur:

-          post discharge (ex: transition from ED to home)

-          ambulatory areas (surgical suites, emergency department)

-          shift changes

·         Agree on which specific tests require communication, and establish a shared policy for uniform communication for all types of test results (lab, radiology, pathology, etc.) to all recipients.

·         Build in reliability: Create tracking systems to assure timely and reliable reporting of test results; require an acknowledgment of receipt of test results by the provider who can take action

·         Provide ongoing education on procedures for communicating critical test results to all healthcare providers (physicians, nurses, lab personnel, all other clinical disciplines)

·         Monitor effectiveness of systems (call schedules, feedback loops, response times, number of “lost” test results)

·         Support infrastructure development.  To the maximum extent possible, hospitals should adopt advanced communication technologies, and improve laboratory and other testing system capabilities.

The Massachusetts Coalition for the Prevention of Medical Errors has studied this issue extensively. The Coalition has developed a group of Best Practice Recommendations that hospitals should try to implement, to improve their ability to provide timely and reliable communication of CTRs. This information can be found at: The Coalition’s “Safe Practice Recommendations” was published in Feb. 2005 issue of the Joint Commission Journal of Quality and Patient Safety, Vol. 31, No. 2, http://www.jcrinc.com

Massachusetts Coalition for the Prevention of Medical Errors

5 New England Executive Park

Burlington, MA  01803

(781)-272-8000, ext.124

http://www.macoalition.org

We suggest the following actions for Primary Care Physician Practices:

• Develop and implement systems that address critical value test results, to ensure that clinical information crucial to an accurate diagnosis and follow-up is received and handled by the office, and that it reaches the responsible physician quickly. This may involve a checklist for staff that identifies information that is considered urgent.

• Develop and implement an internal system for following up to ensure that recommended tests or consults are actually completed as ordered.

• Develop a system which requires office staff to confirm, before patient documents (lab test results, consult reports, etc) are filed, that patients are promptly notified of abnormal test results, along with any recommended course of action.

• Document when the patient chooses not to follow up on recommended tests or referrals and that the patient has been advised of the consequences of not following up on testing recommendations or referrals.

Summary

The three cases discussed in this article were selected because they illustrate the importance of developing systems, policies and procedures for reviewing, reporting and acting on patients’ critical test results.  

The process of test ordering, sample testing and results reporting involves many departments (nursing, ED, laboratory, radiology, etc.) and communication by many different personnel. The scope of this issue cuts across all clinical areas, inpatient as well as ambulatory settings.