Jonathan, there is a lot published about this and there are some recommendations, mostly coming from the US.
Suggest J Qual and Patient Safety February 2005 Volume 31 Number 2 - the whole issue is about how to communicate critical results.
One paper in this is particularly helpful in answering your questions by Hanna D et al: Communicating Critical Test Results:Safe Practice Recommendations.
Another one also making recommendations is: Singh H and Vij MS: National Patient Safety Goals Eight Recommendations for Policies for Communicating
Abnormal Test Results. The Joint Commission Journal May 2010 Volume 36 Number 5: 224-236. This paper also present a process map for calling results and escalating alert calls to different levels (attached)
A few other useful papers (but there are many more):
1. Genzen JR et al. Pathology Consultation on Reporting of Critical Values. Am J Clin Pathol 2011;135:505-513
2. Wagar et al. Assessment Monitoring of Laboratory Critical Values A College of American Pathologists Q-Tracks Study of 180 Institutions. Arch Pathol Lab Med, January 2007; Vol 131:44-49
3. Wagar et al. Critical Values Comparison A College of American Pathologists Q-Probes Survey of 163 Clinical Laboratories. Arch Pathol Lab Med. 2007;131:1769-1775
4. Dighe et al. Survey of Critical Value Reporting and Reduction of False-Positive Critical Value Results. Arch Pathol Lab Med. 2008;132:1666-1671
5. Piva et al. Assessment of critical values policies in Italian institutions:
comparison with the US situation. Clin Chem Lab Med 2010;48(4):461-468
6. Piva et al. Evaluation of Effectiveness of a Computerized Notification System for Reporting Critical Values. Am J Clin Pathol 2009;131:432-441
This again offers a process flow chart
Just to inform mailbase readres, CLSI is working on a guideline for communicating critical and significantly abnormal results. This document might fill in some existing gaps in and decrease variations of the practice of critical result reporting in many countries.
Regards, Rita
Prof. Andrea Rita Horvath, MD, PhD, EurClinChem, FRCPath, FRCPA
Past President of the European Federation of Clinical Chemistry and Laboratory Medicine
Clinical Director, SEALS North, Department of Clinical Chemistry
Level 4, Campus Centre, Prince of Wales Hospital
Barker Street, Randwick, NSW 2031, Sydney, Australia
Tel: (+612)-9382 9078
Fax: (+612)-9382 9099
Mobile No: (+61)-404 027 843
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2nd EFCC-UEMS European Joint Congress
Laboratory medicine at the clinical interface
10-13 October, 2012 - Dubrovnik, Croatia
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-----Original Message-----
From: Clinical biochemistry discussion list [mailto:[log in to unmask]] On Behalf Of Jonathan Kay
Sent: Friday, 13 July 2012 2:41 AM
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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