ABSTRACT
Emergency department (ED) physicians like to stay on top of laboratory results. Whenever a laboratory assay produces a critical value, the laboratory software sends a message to a technician at the laboratory call center regarding the value, as well as information on the patient and where the order came from. Corrections to the laboratory call center system were implemented within a little over 2 weeks. The root-cause analysis revealed that a change to the registration system meant the laboratory system was sending new messages to the laboratory’s call center system, which was not properly configured to receive them. A simpler process where the laboratory technician just paged the ordering provider was rejected because too many ED providers were unreachable after their shift ended. The ED charge nurse, in turn, would find ED providers taking care of the patient to let them know about the critical value.
