ABSTRACT
Failures of communication and follow-up of abnormal diagnostic test results can lead to errors, adverse events, and liability claims.[1-5] Therefore, The Joint Commission has prioritized safe and timely communication of critical test results as a National Patient Safety Goal (NPSG.02.03.01), “Report critical results of tests and diagnostic procedures on a timely basis.” [6] Although communication breakdowns are deemed largely preventable, this goal remains one of the most commonly cited areas of noncompliance in routine surveys. [7] The evolving defi nition of “critical” results adds further complexity to the problem. In laboratory medicine, a critical (or panic) laboratory value represents a “pathophysiologic state at such variance with normal as to be life threatening if an action is not taken quickly and for which an effective action is possible.” [8[ (p. 709) It is now thought that this defi nition should include equally important but less time-sensitive “vital” values. [9-12]
Emerging evidence highlights vulnerabilities in test-result communication practices along the entire spectrum of testresult abnormality and severity. [5,13-17] The risks of communication breakdowns apply not only to critical values but also to abnormal but non-life-threatening test results. The latter are especially pertinent in the outpatient setting. For example, many test results (for example, chest x-ray with a suspicious shadow), although neither immediately life threatening nor requiring immediate attention, require a response by the provider in a relatively short (1-2 week)
period of time. These results may not warrant direct verbal communication to providers; other means of indirect communication such as secure fax, e-mail, or the electronic medical record (EMR) are appropriate for this intermediate level of urgency. In March 2009, the Veterans Health Administration (VHA) released a directive recommending that test results be communicated to providers “within a timeframe allowing prompt attention and appropriate action to be taken” and to patients so that “they may participate in health care decisions.” [13] Although apparently reliable electronic systems are used to communicate abnormal test results, breakdowns in test result follow-up persist. [15,18] For example, our recent work on automated EMR-based notifi cations of diagnostic test results within the Department of Veterans Affairs (VA) outpatient setting showed that 7% of abnormal laboratory results and 8% of abnormal imaging results lacked timely follow-up despite evidence of transmission to providers. [19,20] This is consistent with work in non-VA settings, where approximately 7% of abnormal diagnostic test results were either never communicated to the patient or the disclosure was undocumented. [14]
Therefore, evidence-based and practical institutional policies must uphold effective processes to guide communication of abnormal test results. [21] In 2004, we implemented a policy at our institution (Michael E. DeBakey VA Medical Center, Houston) in response to two separate incidents of small lung nodules detected on chest x-rays that went on to develop into unresectable lung carcinomas in the absence of any follow-up. We recently revised this policy in light of new guidance from the VA Central Offi ce, updated Joint Commission National Patient Safety Goal requirements, and evidence from both within and outside our institution. This article describes the rationale of our institutional policy and provides general recommendations, on the basis of our previous work, other literature, and sound clinical practice, for creating or updating similar policies at other institutions.
