LABORATORY POLICY AND PROCEDURE TITLE/SUBJECT: Critical Test/ Critical Result Reporting FILE NUMBER: QA 030.05 ASSIGNED MANUAL: Quality Assurance ORIGINATION DATE: 11/31/2006 EFFECTIVE DATE: 01/07/2015 DISTRIBUTION: All of Saint Michael s Hospital Laboratories PRINCIPLE/PURPOSE: Ministry Saint Michael s Hospital and Ministry Medical Group-Central Region will communicate the results of tests considered critical to patient care to the responsible licensed caregiver in a timely and reliable manner according to established guidelines. 1.0 To prevent delays in taking actions in responding to critical tests and critical results that may have the potential for serious harm to the patient. 2.0 To define critical tests and critical results. 3.0 To establish a communication processes with the responsible licensed caregiver 4.0 To develop a system for measuring and assessing the timeliness of reporting critical tests and critical results with the goal of ensuring timely reporting. DEFINITIONS: Critical Test Result: Those test results that fall significantly outside the normal range and/or may represent life-threatening values, even from routine tests and that require rapid communication of results to the responsible caregiver. A delay in taking action to respond to the result may result in a serious adverse outcome for the patient. In addition, panic/alert/critical results as defined by reference laboratories will be used for tests completed outside the organization. Critical test results are defined by the performing department in collaboration with Ministry Saint Michael s Hospital and Ministry Medical Group-Central Region medical staff. Timeliness of reporting critical test results: The acceptable length of time between completion of the test (identifying the critical result) and receipt by the responsible licensed caregiver will be within one (1) hour unless: a) The provider documents specific diagnostic notification range values in the medical record, or b) The critical value is improved from a previous value and the provider is aware of the previous value.
Authorized Staff: The following health care professionals may act as authorized staff: Registered Nurses, Licensed Practical Nurses, Medical Assistants, and Respiratory Practitioners. Responsible Licensed Caregiver: Physicians, Physician Assistants, Nurse Practitioners, and Advanced Practice Nurse Prescribers. Subsequent / Sequential critical results: Clinical judgment, based on patient status, determines if these results are to be communicated to the physician as a critical result. Communicating critical tests/ critical results to the responsible licensed caregiver It is acceptable for results of critical tests and critical results to be communicated to authorized staff members who would then be accountable for communication to the responsible licensed caregiver. When the patient s responsible licensed caregiver is not available within the time frames, the information will be reported to an alternate responsible licensed caregiver. In the event that a patient s provider cannot be reached and does not respond to a call/page, the call will be repeated in 15 minutes. If successful contact cannot be established, the on-call physician will be paged. If no response, follow the chain of command. To ensure accurate communication, telephone reporting of results from critical tests (normal or abnormal) or critical results, requires a read-back of the information by the person receiving the test result. The person receiving the test result will write down the result (if possible) and read it back to the person providing the result. The person providing the test result will confirm the information was read back. For Ministry Saint Michael s Hospital Laboratory, the read-back process is documented in the medical record. Results from critical tests and critical results must be called after verification in the laboratory. Results are called to authorized staff or the responsible licensed caregiver. Results on patients designated as temp location or Operating Room will be sent directly to the O.R. printer. Additionally, call the O.R. to notify that it s printed. Measure and assess timeliness of reporting critical tests/ critical results Data is collected by the appropriate departments based on concurrent observation or retrospective medical record review and sent to the Quality Department for compilation and creation of monthly and quarterly reports. Data measuring the timeliness of reporting critical test results is discussed at various meetings, including the Joint Commission Core Team. Time frames are analyzed to determine whether improvements in timeliness of reporting are needed. If improvements are needed, action plans will be created. Page 2 of 7
Critical Tests OR frozen section See attached chart for specific critical lab values Special circumstances Tests may be done in departments (e.g. ICU or WIC) where provisions have been made by the physician provider for the clinical management of critical results, such as a signed order set for electrolyte replacement or glucose management via insulin drop titration. These tests may have critical results, but the nurse, following the appropriate parameters as set forth in the respective orders set, will respond on behalf of the provider. Specific Examples for Critical Laboratory Results and Critical Tests. 1.0 Calling of Critical Laboratory Values and critical tests to caregivers or designees Critical Values and other laboratory results called to health care staff or designees must be documented in the MEDITECH system and be done within time frames established. Each laboratory has developed a list of results to be called to physicians or other clinical personnel responsible for patient care. In addition, critical values as defined by reference laboratories will be called to afore mentioned. The following is the format that should be used for calling /documenting all results: Use canned text "LCALL" to document that you called a critical value listed on the attached Critical Value List to someone other than a provider: Called [] [now] [today] [user]. Will you be able to tell the provider these critical results immediately? [] Results read-back by caregiver with assurance that critical results will be delivered to the provider immediately. EXAMPLE: Called LK, RN 1402 01/07/06 JS Will you be able to tell the provider these critical results immediately? Y Results read-back by caregiver with assurance that critical results will be delivered to the provider immediately. Use canned text "LCALLMD" to document that you called a critical value listed on the attached Critical Value List directly to the provider: Called [] [now] [today] [user] Results read-back by provider. EXAMPLE: Called TJM,MD 1402 01/07/06 KS Page 3 of 7
Results read-back by provider. Use canned text CALL to document that you called a result to a licensed caregiver that is not deemed as a critical value: Called [] [now] [today] [user]. Results read-back by caregiver. Please report these results to the provider. EXAMPLE: Called MT, RN 0650 01/31/08 MW Results read-back by caregiver. Please report these results to the provider 2.0 Result Read Back Policy This process will be utilized in the taking of verbal or telephone orders and the calling of results to providers. All diagnostic tests including laboratory tests and other diagnostic tests to include any test/ result which require an urgent response must be read back by the person receiving the results. Calling of test results must be documented in the MEDITECH system as described in the calling policy. In addition it must be indicated that the results were read back by the person receiving the results. Example: CALLED MT, RN 0650 01/31/06 MW Will you be able to tell the provider these critical results immediately? Y Results read-back by caregiver with assurance that critical results will be delivered to the provider immediately. SAFETY PRECAUTIONS: Follow procedures and precautions described in the Saint Michael's Hospital Infection Control and Hazard Communication manuals, as well as the Saint Michael's Hospital Chemical Hygiene Plan. Refer to the MSDS for reagent-specific handling guidelines. ATTACHMENTS: Critical Value Chart REFERENCES: The Joint Commission - National Patient Safety Goals Ministry Health Care Critical Test Reporting Policy MSMH and MMGCR (PHY-037) Page 4 of 7
ORIGINATING DEPARTMENT/SECTION: Saint Michael s Hospital Laboratory QA030.05 CRITICAL TEST&CRITICAL RESULT REPORTING 3rd Edition AUTHOR AND DATE: Rod Hoeth, MT-ASCP Laboratory Supervisor 11/30/2006 REVISED BY AND DATE: Rod Hoeth, MT-ASCP Laboratory Supervisor 02/16/2009 Dawn Finch- Laboratory Supervisor 08/10/2009 Michelle O Connell, MT (ASCP) Quality Improvement Coordinator 01/18/2010 Michelle O Connell, MT (ASCP) Quality Improvement Coordinator Edits include removal of non-lab related information (ie: Diagnostic Imaging Criticals) January 7, 2015 APPROVAL: Dawn Finch, MT (ASCP) Director of Laboratory Services Jason Heese, MD Medical Director of Laboratory Services S:\Lab\Lab Manuals\Quality\CRITICAL TEST&CRITICAL RESULT REPORTING 3rd Edition.doc Page 5 of 7
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