Critical Test Value Reporting: Audit Current Processes to Initiate Improvement

Failure to timely communicate patient information. Delay in diagnosis. Delay in treatment. These all have the potential to result in patient injuries, deaths, and other adverse outcomes—and litigious allegations—when communication of critical test values is not timely or accurate. Critical test value reporting recently gained prominence when the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) incorporated related requirements in its 2005 National Patient Safety Goal that addressed improving communication among caregivers.

Critical test results encompass laboratory tests as well as all diagnostic tests, including imaging studies, electrocardiograms, and other diagnostic tests and studies. They include panic value reports, stat tests, and any other test results that require urgent consideration or action. Timely communication of such test results has always been important from a quality and patient safety standpoint: Are clinicians notified of test results so that they have adequate time to make appropriate therapeutic decisions? Do current patterns of communication regarding critical test results ever contribute to negative patient outcomes?

A researcher who conducted a retrospective study on the promptness of response to critical laboratory test results noted, "The purpose of laboratory testing is not served until the appropriate caregiver receives and reviews the results and takes any necessary clinical action."1 However, a study published in 2002 found that the ordering or on-call physician was reached only 12% of the time when labs attempted to communicate critical test results.2

Early in 2003, the Massachusetts Coalition for the Prevention of Medical Errors (MA Coalition), an organization established in 1998 to increase patient safety in Massachusetts through education and strategy-sharing, began exploring ways to improve the reporting of critical test results. Drawing on the experience of hospital teams participating in a learning collaborative on this initiative, the MA Coalition has been able to compile...