Jonathan
CPA standard G3.1 would seem to address the mechanisms by which a sodium of
164 mmol/L would be communicated to those caring for a patient. As a Peer
Assessor I see many examples of good practice which occasionally extend
beyond that mentioned in the department's SOP. We must not forget that the
decision to phone may be in the hands of a relatively junior BMS and on
direct questioning I am reassured how many Band 5s/6s will go the extra mile
to ensure that a significantly abnormal result will get through to the
clinical staff - key to the conversation is identification of which result
is the significant one and emphasising that it must be given to the
clinicians caring for that patient. Good labs will always log the call,
ideally on the LIMS. I believe that it's the responsibility of the Head of
Department to ensure such systems are in place and to ensure that staff have
easy access to phoning limits and guidance and also encourage staff to ask
for advice whenever they are unsure of whether to phone or even, if
necessary to go up to the ward in person or have a Consultant to Consultant
conversation
What worries me is those labs with hub and spoke arrangements and unexpected
results turning up in cold work - but that's quite another debate.
Regards
Jeff
Jeff Slater Consultant Clinical Scientist (Retd)
-----Original Message-----
From: Clinical biochemistry discussion list
[mailto:[log in to unmask]] On Behalf Of Jonathan Kay
Sent: 12 July 2012 17:41
To: [log in to unmask]
Subject: The safety implications of missed test results for hospitalised
patients
I received no replies about good procedures, apart from the observation that
if you communicate it yourself you know that it's been communicated.
Are there really no relevant systems, SOPs, studies or audits that you can
share?
Jonathan
On 6 Jul 2012, at 17:18, Jonathan Kay wrote:
>
> . this isn't covered by CPA, as far as I know, but may well affect your
organisation's risks, as assessed by the NHS Litigation Authority.
>
> Does anyone have any good procedures, or studies, about how to make sure
that reports get to the right person, and how you can know that they have?
>
> Jonathan
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