Relay Center Helps Hospital Better Manage Test Results

In the University of California, San Francisco (UCSF) Medical Center’s quest to better manage test results, “the relay center is the focal point of the solution that we arrived at,” said Susan Penney, J.D., director of risk management, UCSF Medical Center, during a June 14, 2012, conference call hosted by the American Health Lawyers Association’s Enterprise Risk Management Task Force. A high-dollar settlement following a patient’s death from stage 4 lung cancer spurred the hospital to address the issue. The patient initially presented to the emergency department with an unrelated complaint; a computed tomography scan revealed a nodule that needed follow-up in three to six months, but the result was never communicated. Afterward, the hospital formed a multidisciplinary task force on test results. A failure mode and effects analysis identified the top three vulnerabilities: inconsistencies in identifying and documenting the name of the patient’s primary care provider (PCP), the “porous process” for notifying physicians of test results, and inconsistencies in notifying patients of test results that might require follow-up. As a result, the hospital changed from an opt-in to an opt-out system during admitting (e.g., having admitting staff say, “We are planning to send your discharge summary to your primary care provider,” and ask patients who their PCP is) and clarified the provider field in the database.