Communication breakdowns are part of life.
Very regularly, well-intentioned people are unclear, misunderstand, or fail to act. Still, communication breakdowns in the reporting of critical medical test results can be catastrophic, so health professionals must continually work to close the loop on systemic issues involving communication, including the timely relaying of critical values, patient handoff from one provider to the next, and follow-through procedures.
There are many contributing factors to diagnostic error, communication breakdown being one of them. To reduce diagnostic error, improve patient safety, and reduce liability risks and possible claims, it’s important not to let critical test results slip through the cracks. It’s an issue that applies to practices of all sizes.
WHY PROBLEMATIC?
One might ask, what’s so difficult about reporting test results? A doctor orders a test, the test is given, a lab delivers the result, the doctor tells the patient, the patient is treated. But information can potentially dead-end at every point in the chain of communication. The more steps there are, and the more people involved, the more chances for error.
Here’s how. A doctor may order a test, but the patient doesn’t get it done. The test may get done, but the tracking system misses that it’s critical. A doctor other than the original provider may receive the result, but not have the context to interpret the result correctly. The patient might be told the result, but not seek the treatment ordered. Or perhaps there’s a conflict in the findings, or they’re inconclusive—say, it’s not clear if a bone is fractured or not—and the medical issue simply gets dropped by both the doctor and the patient.
Error can also occur when a doctor orders a test—say, a study for abdominal pain—and the person interpreting the test—in this example, a radiologist—sees something that could be critical, but is unrelated to the original acute issue. In some cases, that person may not relay the surprise finding or have the provider look into it further, leading to problems down the line.
Dr. Bill Kriegsman, a MultiCare residency faculty member with a background in family practice, obstetrics, and addiction medicine, offers a scenario drawn from his own experience. “If an ultrasound tech were to discover a low fetal heartrate in a patient of mine, they would call me right away and ask for my instructions, because a low heartrate in a fetus is a clear threat to its life and we would need to react right away,” he says. “The patient would be told to go to a birth center immediately, and I would meet her there.” But, he points out, things could still go wrong. “The tech could fail to recognize that the heartrate is low, or fail to understand that the low heartrate is critical,” he says. “If a doctor is covering for me and they receive the call, they might not perceive the level of threat the result represents, or perhaps they’re not familiar with the patient’s history and how the result might be relevant. The critical value then might not be communicated clearly to the patient, and she might not understand how urgent the situation is.”
WHAT’S CRITICAL?
Many diagnostic studies—which could be labs or imaging—with abnormal results have a “critical value,” representing an imminent threat to a patient’s health. The reporting of any result that has critical value is time-sensitive: any delay could turn a problem that was initially treatable into one that’s not.
In both hospital and outpatient settings, policies set by labs and providers define what those critical values are, and the time frame in which they must be communicated. There are national patient-safety goals, set by the Joint Commission, and state health-department expectations. Still, “timeframes for reporting critical values are somewhat dependent on the capability of the individual labs,” says Dr. Kriegsman—and that response discrepancy can leave room for problems to occur.
Inpatient settings have an advantage over outpatient settings in responding to critical test results, because of their ready access to patients. “It’s more complicated with outpatient, because the provider has to decide how to reach the patient, and it can be harder to track people down after-hours,” Dr. Kriegsman says.
HOW COMPLICATED?
“Critical values should be clearly defined, based on single tests and single results, but a single value doesn’t necessarily constitute a threat,” explains Dr. Kriegsman. “The challenge comes in when combinations of values are what makes the situation critical”— patterns of the results within blood tests, for example, as opposed to any one value in the blood count.
Another gray area would be an abnormal result that’s not critical because it’s not an imminent threat, but could become catastrophic over the near term—and depend on the overall health of different patients. Case in point: a positive COVID-19 test. “Obviously, this could be more severe for an elderly person with high blood pressure and obesity than it would be for a healthy 20-year-old,” Dr. Kriegsman notes.
Dr. Kriegsman’s advice to providers for navigating the complications: “For every critical lab result, there has to be a record of acknowledgment that the result was received, and a consideration of what that result means. Documenting your part in the chain of communication shows that your system is working, and you’re doing what you’re supposed to.”
Whether a test result is critical or not, he says, “with any lab result that is unexpected or requires action to be taken, documentation is super important.”