Risk Management: Communicating Critical Test Results

by Lilly Cowan, JD, ARM, CPCU, Princeton Insurance Healthcare Risk Consultant Printable Version of this Article   This Risk Review article is the first in a series in which we will discuss the issue of communicating critical test results. We will begin with an introduction and context of this issue, with a brief review of some of the relevant terminology.  Future installments will address factors that have been identified as contributing to failures in reporting and acting upon critical test results; JCAHO initiatives aimed at improving communication among caregivers, as promulgated in its 2005 & 2006 National Patient Safety Goals; the pioneering work of a group of Massachusetts hospitals (Massachusetts Coalition for the Prevention of Medical Errors and the Massachusetts Hospital Association) in studying this issue and developing Safe Practice Recommendations (guidelines, definitions, implementation issues and strategies to improve communication processes); and finally, we will review several lawsuits, based on Princeton Insurance’s closed claim files, that may serve to illustrate how errors in the process of communication of test results can compromise care and lead to allegations of professional liability.   Introduction It is generally recognized that communication is a key component in delivering quality healthcare services.  We are living in an era when communication and information technologies are developing so quickly that it can be difficult to keep current. Similarly, hospitals and other healthcare facilities are struggling to keep pace with and adapt to the rapid and frequent changes in information technology, both in clinical areas and administrative functions.      In fact, there appears to be a dichotomy in modern medicine. On the one hand, diagnostic clinicians have access to an array of powerful, technologically advanced tools to detect and diagnose disease at ever earlier stages. On the other hand, despite the proliferation of “high-tech” smart devices designed to aid communication –  cell phones and PDAs with e-mail and instant messaging, voicemail and pagers, to name just a few –  technology has not yet eliminated breakdowns in the communication process between patients and providers and among caregivers. Rather, it appears that the “increasingly complex healthcare environment can complicate the communication process and hinder information exchanges necessary for optimum care.” [i]   When the communication process in health care fails – such as when critical information is delayed, forgotten or misdirected, not transmitted completely or accurately - it can result in adverse patient outcomes. In fact, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has found that communication-related problems were the most frequently cited cause of sentinel events reported to it over a 10 year period. [ii]   Reporting Critical Test Results: A Safety Issue This article focuses on one aspect of communication that continues to present challenges: the reporting of critical test results and values (CTRs).  Failures and/or errors in the process of notifying the responsible provider of important, abnormal diagnostic test results have the potential to cause serious negative outcomes for patients, including delayed diagnosis and treatment, even injury and death.  In addition, such reporting failures put healthcare facilities and caregivers at risk of malpractice claims.   Many healthcare authorities, including JCAHO, the Institute of Medicine (IOM), and the Agency for Healthcare Research and Quality (AHRQ), have recognized that the failure to report critical test values in a timely and reliable way is a threat to patient safety and healthcare quality.  JCAHO clearly emphasized the importance of this issue when it incorporated CTR-related requirements in its 2005 National Patient Safety Goal that deals with improving communication among caregivers.[iii] [i] ECRI. Communication. Healthcare Risk Control Risk Analysis, 2006 July; Supplement A: Risk and Quality Management Strategies 17; (p. 1 of 21)   [ii] Joint Commission: Root Causes of Sentinel Events (All categories; 1995-2004) [online] 2005 Dec 31 [cited 2006 Apr 6] Available from Internet: http://www.jointcommission.org/SentinelEvents/Statistics   [iii] JCAHO. FAQs about the 2005 NPSGs [online]. Available from Internet: http://www.jointcommission.org/accredited+organizations/patient+safety/05_npsgfaqs.htm

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