Thank you to the dozen or so that replied to my posting - here is an anonymised compilation.

My question was prompted by two recent cases with different errors, and it seems that to me that what was once useful additional help of a call from from the lab has now become an essential crutch that the requestor does not expect to do without.  This has coincided with electronic reporting of paper requests where, if the patient is identified correctly, I am not sure of the grounds for non-analysis because the electronic report will be available without doubt as to the identification of the patient.

The long term answer to data quality is more widespread electronic requesting, the short term is "do what you can" and with a large renal unit (including home haemodialysis with pre-dialyisis gravity-separated heparinised serum) and delays in sample transport it is getting more difficult to remain vigilant.

Thank you very much to the sender of an SOP about this which seems to transfer the responsibility to the lab staff to do something - this is fine, and it makes failure to communicate even more explicit.

Out of hours requests, no contact numbers, phones not answered, answering machines - I'm not sure that this issue has a "one size fits all answer" - does anyone else see a simple way through without just leaving it to the discretion of senior staff?

Kind regards

Andrew










•       We operate in a different environment here - a competitive market, where the patient has the freedom to chose where they have their specimens taken and analysed. In Australia, the RCPA has a guideline for communicating high risk results (available via http://www.rcpa.edu.au/Library and under the "Guidelines" heading) that discusses escalation policies for critical results. For outpatients, if the doctor is not contactable, or does not have after hours deputising service available (see below), then our guidelines indicate we should be attempting to contact the patient and, should that fail, consider contacting emergency services (e.g. police welfare check) depending on the nature of the result.

Unfortunately it has been my experience that many GP's do not provide their mobile numbers to laboratories. Many practices 'close up shop' after-hours and either do not have an after hours deputising service (usually a private company with GP's on staff that coordinate GP home visits if a patient of the practice is unwell after hours) or do not give their out of hours contact details to the deputising service for the rare occurence of a life threatening laboratory result for one of their patients. After-hours GP's, who do not know the patient, are often extremely reluctant to take ownership of a critical result.

Medicolegally, it's a bit of a grey area. Lawyers tell us that it's the laboratories responsibility to maintain accurate phone numbers for their clients (including after hours ones). It is also the doctor's responsibility to follow up test results. Pathologists also have a duty of care to their patients. The Royal Australasian College of GP's is drafting updated clinical practice guidelines for continuity of care after-hours.

Thus, I have phoned patients at home many times (usually advising hospitalisation) and emergency services occasionally.

•       Actually the scenario you are quoting is very difficult .
If I face something like this, I will try to follow the policy of communicating abnormal, critical results (attached). If I could not find the requesting Dr, I will try to find the patients phone number or nearest GP clinic
Regarding Isolated Hyperlkalemia, I think; still it needs to be communicated as well and I would think to alert the requesting clinican about medications (spironolactones, ACE,ETC) and pseudohyperkalemia

•       On the occasions where I've found myself in this situation, I've gone onto our PAS system (PPM+) and checked the patient history. This has always given me the information I required to track someone down, who then gets an earful. Respectfully, of course.

•       Assuming no evidence of e.g. EDTA contamination...
* Check hospital systems (PAS) for any record of admissions/OPD appointments (if I can't access it, Switchboard usually can).
* Check for previous, recent results with a location/GP information.
* Inform NHS 111 if no success and see if they're willing to try and hunt the patient down.
* Report as a clinical incident. and remind myself that the responsibility for checking results always lies with the requesting clinican so that I can sleep that night.

•       Unfortunately the scenario you presented is quite common!
When I come across this type of situation (this happens a lot with some of our out-patient clinic samples), I would check previous records, both on LIMS and EPR for any up to date information about a clinician/GP in charge. I'd phone the GP and inform of the results - so far, I haven't come across any issues with this plan. GPs are generally quite helpful and will act on it.
If its OOH, then our policy is to call 111 - I usually check the next morning to see if there are any repeats/A&E admissions etc. If we have GP details then I'd call the surgery the next morning to make sure they have received the results and the doctor is aware of it.

If it's an in-patient sample - then I'd do the same checks on LIMS and EPR for the latest ward/clinician info - we have a number that we can call to locate a patient (bed# etc), which would be my next port of call.

If no previous record whatsoever (not happened to me yet), then I guess calling NHS 111 would be my last resort.

In answer to your question about normal creatinine with high potassium - yes, I'd still phone it if all the causes of pseudohyperkalamia check out.

•       CONTACT PATIENT AND ASK THEM WHO DR WAS.

•       We would look to see if we had another recent request for the patient and try to contact that requestor. If previous requests show it to be a cancer patient we would contact the oncology ward, sometimes they know the patient.

This is beyond the area where simple rules apply. If the creatinine is high one would be more inclined to involve someone, like a GP who previously sent investigations, after hours. Less so if there are previous normal potassium levels and the creatinine has not changed. Or if the sample time is on the form and the sample is clearly several hours old (but it probably won't be....).

But sometimes the best one can do is just as you say - report it electronically and hope someone picks it up.

•       If there is no location or requestor then this fails our acceptance criteria and it should not be analysed.....but people do usually book it in and send result to the most recent GP....if definitely no previous known location/doctor then we put it in as unknown and don't analyse it.

•       We have recently implemented a policy of zero tolerance for incomplete request forms - so this one would have failed on the basis of lack of clinical details & illegible requestor and never been assayed.

Before implementation of this policy I would have accessed the hospital PAS & tried to locate the patient/consultant.  Failing that it would have been a call to the patient's GP - assuming we could track him/her down.

•       I'm presuming no previous to see who was in prev. care of this patient?  It would seem reasonable to ask the IT dept to put an alert across the hospital IT system re the patient/date/time of event/result (no evidence of delayed separation so I'm presuming too you know the date [+ time] of collection). To attract attention, an email circular too amongst hospital users and perhaps to a GP liaison to cascade to others in the region.

We don't know if chronic or acute renal but I would think it does not make a difference even if the creatinine was normal particularly as we nothing re patient, cardiac hxm, arrhythmia  etc

I see this discussion going down the line of where does the legal obligation sit, lab or user? It would seem reasonable for the lab to make some effort to reach out to users, if indeed it is a sample from a user of the service (within hospital or contracted external GP/hospital etc user).

I don't think our lab policies or SOPs tackles this one or state where the duty of responsibility sits (shared?)

•       We would ensure it is phoned to somewhere (if creat raised). We would look at the history to start with and then take it from there.

If the creat was normal, I would want to exclude pseudo (delayed sample, platelets etc) but would probably be less concerned and simply ask for an urgent repeat.

•       We are fortunate in that we have complete separation of GP and acute work (it goes to different places) - if it is from within hospital, it's not too difficult to track down if we need to. For GPs, we pass on to OOH service with all info we have

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