Effective Notification Matters! Answering the Call of Duty

Throughout my career as a laboratory medicine professional, I have had the privilege of holding several technical and administrative positions in public and private laboratory hospitals.

As a laboratory scientist, it is quite common to obtain abnormal and critical results from automated analyzers after examining blood samples or body fluids.

One of the cases that I clearly remember happened while I was working in the hematology laboratory. One of the family doctors had ordered a Cell Blood Count (CBC) on a 40-year-old, male patient. After processing the blood sample, I became aware of his marked anemia, elevated white blood cell count, significant reduction in platelets, and a few other parameters, all potential indicators for acute leukemia.

As a new patient with no medical history in the system, I proceeded to follow the laboratory policy and repeated the test to confirm the previous values. The results were almost identical.

My reaction was immediate: in keeping with the protocol for "critical values reporting," I picked up the phone and called the doctor who had ordered the test. The phone rang a few times and went to voicemail. The doctor had finished his shift and was not available. It was a very stressful moment and I knew that every second mattered. I reviewed the procedure again and I found the clause that instructed the staff on what to do in the event that the primary care provider (PCP) is not available.

I called one of the physicians in the hospital's emergency department and reported the CBC result. The emergency physician immediately contacted the patient and asked him to come to emergency department as quickly as possible. I later learned that the patient had been treated without delays and that after performing additional bone marrow and genetic testing, his leukemia was classified as Pro-Myelocytic (APL), a class of acute leukemia that evolves very aggressively and that, if left untreated, can be fatal.

Critical Values

Communicating critical values in a timely manner is important for proper patient management and treatment. During this process, several variables such as erroneous results, delays in communication, or results given to the wrong physician can cause inadequate management of the patient, which is troubling. This crucial information can often be used to save a patient’s life.

The College of American Pathologists (CAP) defines Critical Values as those results that may require rapid clinical attention to avert significant patient morbidity or mortality.

The transfer of information within health organizations takes place at various points in clinical management. One of them is the one that occurs among health professionals, for example, from doctor to doctor, from nurse to doctor, or from laboratorian to doctor.

Communication failures can occur at various points in patient care and can result in adverse events. Interruptions and other distractions from unit activities can inhibit clear communication of important patient information. Standardized and critical content for communication between patient, family, caregiver, and healthcare professionals can significantly improve outcomes related to handovers of patient care (JCI Standards 7th Edition. Standard IPSG 2).

The WHO’s World Alliance for Patient Safety has identified poor follow-up of critical or significantly abnormal test results as one of the top contributors to unsafe care.

Within the communication process, there are several challenges that the laboratory professional may encounter. One of them is that many organizations have not defined the critical values of those laboratory tests that are considered life treating. The second most frequent challenge is the lack of an escalation protocol for cases where the attending physician is not available. In other occasions, laboratories struggle to have effective methods of communicating these results due to lack of technology.

Policies and Procedures Are Essential

Diagnostic tests are performed in a variety of disciplines, including laboratory, imaging, and cardiac diagnostics. Critical results may also be produced from any diagnostic tests performed at the bedside, such as point-of-care testing, portable imaging, and electrocardiograms (JCI Standards 7th Edition. Standard IPSG 2).

Globally recognized accreditors such as the Joint Commission International (JCI), the Council for Health Service Accreditation of Southern Africa (COHSASA), and Accreditation Canada have incorporated standards and measures that ensure the development and implementation of policies and procedures for the immediate reporting of alarming results.

A good protocol should include the documentation of results called, the person who received the results, the date and time they were called, as well as the name of the person who reported them and have a field/column to verify that the result was "read-back" by the receiver. 

In addition, it is recommended to include instructions of who to call in case the attending physician is not available (contingency plan) and who is responsible for reporting the critical results of the tests that are sent to a referral laboratory.

Having an adequate system to cover such communication of results is an explicit requirement of ISO 15189:2012, clause 5.9.1. Effective communication, which is timely, accurate, complete, unambiguous, and understood by the recipient reduces errors and results in better patient safety.

Your turn!

The first step is to define the list of diagnostic tests that should be considered as critical and the values for which a delay in reporting can lead to serious adverse outcomes for patients. Then, develop and implement policies and procedures for the proper management and reporting of those critical results.

For those organizations that already have the protocols, I invite you to evaluate the effectiveness of your protocol. I also encourage you to use any challenge or problem that you have encountered during the process of reporting critical results as an opportunity to improve and to proactively seek feedback from your clinicians and other healthcare providers. 

If we apply the philosophy of continuous improvement, we will ensure a better quality of care delivery and better patient safety outcomes!

IFC developed free online training on Improving Effective Communication. To update your knowledge and train your staff check here: https://olc.worldbank.org/content/improving-effective-communication-self-paced