Eight recommendations for policies for communicating abnormal test results

Joint Commission Journal on Quality and Patient Safety

Volumn 36, Issue 5, 2010, Pages 226-232

  Singh, Hardeep ^a,b,c   Vij, Meena S ^b,d  

^a DEPARTMENT OF VETERANS AFFAIRS   (United States)

^b BAYLOR COLLEGE OF MEDICINE   (United States)

^c VA Center of Inquiry   (United States)

^d MICHAEL E DEBAKEY VETERANS AFFAIRS MEDICAL CENTER   (United States)

Author keywords

[No Author keywords available]

Indexed keywords

ARTICLE; DIAGNOSTIC TEST; HEALTH CARE SURVEY; HUMAN; INFORMATION DISSEMINATION; INTERPERSONAL COMMUNICATION; MANAGEMENT; POLICY; UNITED STATES;

DIAGNOSTIC TESTS, ROUTINE; HEALTH CARE SURVEYS; HUMANS; INFORMATION DISSEMINATION; ORGANIZATIONAL POLICY; POLICY MAKING; TRUTH DISCLOSURE; UNITED STATES;

EID: 77953399796     PISSN: 15537250     EISSN: None     Source Type: Journal    
DOI: 10.1016/s1553-7250(10)36037-5     Document Type: Article

References (36)

1. Gandhi T.K., et al.: Missed and delayed diagnoses in the ambulatory setting: A study of closed malpractice claims. Ann Intern Med 145: 488-496, Oct. 2006.
2. Singh H., et al.: Reducing diagnostic errors through effective communication: Harnessing the power of information technolog). J Gen Intern Med 23: 489-494, Apr. 2008.
3. Singh H., et al.: Missed opportunities to initiate endoscopic evaluation for colorectal cancer diagnosis. Am J Gastroenterol 104: 2543-2554, Oct. 2009. Epub Jun. 23. 2009.
4. Singh H., et al.: Errors in cancer diagnosis: Current understanding and future directions. J Clin Oncol 25: 5009-5018, Nov. 2007.
5. Hickner J., et al.: Testing process errors and their harms and consequences reported from family medicine practices: A study of the American Academy of Family Physicians National Research Network. Qual Saf Health Care 17: 194-200, Jun. 2008.
6. The Joint Commission: 2010 National Patient Safety Goals (NPSSGs). http//www.jointcommission.org/PatientSafety/NationalPatientSsafetyGoals/ (last accessed Mar. 19, 2010).
7. The Joint Commission: Approved: 2010 National Patient Safety Goals. Jt Comm Perspect 29: 1, 20-31, Oct. 2009.
8. Lundberg G.D.: Critical (panic) value notification: An established laboratory practice policy (parameter). JAMA 263: 709, Feb. 2, 1990.
9. Piva E., et al.: Evaluation of effectiveness of a computerized notification system for reporting critical values. Am J Clin Pathol 131: 432-441, Mar. 2009.
10. Visscher D.W.: What values are critical? Am J Clin Pathol 130: 681-682, Nov. 2008.
11. Lundberg G.D.: It is time to extend the laboratory critical (panic) value system to include vital values. MedGenMed 9: 20, Jan. 2007.
12. Howanitz HJ., Steindel S.J., Heard N.V.: Laboratory critical values policies and procedures: A College of American Pathologists Q-Probes study in 623 institutions. Arch Pathol Lab Med 126: 663-669, Jun. 2002.
13. Department of Veterans Affairs, Veterans Health Administration: VHA Directive 2009-019: Ordering and Reporting Test Results. Mar. 24, 2009. http://www.va.gov/vhapublications/ViewPublication.asp?pub-ID-1864 (last accessed Mar. 19, 2010).
14. Casalino L.P., et al.: Frequency of failure to inform patients of clinically significant outpatient test results. Arch Intern Med 169: 1123-1129, Jun. 2009.
15. Gordon J.R., et al.: Failure to recognize newly identified aortic dilations in a health care system with an advanced electronic medical record. Ann Intern Med 151: 21-27. W5, Jul. 2009.
16. Moore C., et al.: Timely follow-up of abnormal outpatient test results: Perceived barriers and impact on parient safety. J Patient Saf 4: 241-244, Dec. 2008.
17. Singh H., et al.: Using a multifaceted approach to improve the follow-up of positive fecal occult blood test results. Am J Gastroenterol 104: 942-952, Apr. 2009. Epub Mar. 17, 2009.
18. Kuperman G.J., et al.: How promptly are inpatients treated for critical laboratory results? J Am Med Inform Assoc 5: 112-119, Jan.-Feb. 1998.
19. Singh H., Thomas E., Petersen L.A.: Notification of laboratory test results in an electronic health record: Do any safety concerns remain? Am J Med 123: 238-244, Mar. 2010.
20. Singh H., et al.: Timely follow-up of abnormal diagnostic imaging test results in an outpatient setting: Arc electronic medical records achieving their potential? Arch Intern Med 169: 1578-1586, Sep. 28, 2009.
21. Hanna D., et al.: Communicating critical test results: Safe practice recommendations. Jt Comm J Qual Patient Saf 31: 68-80, Feb. 2005.
22. The Joint Commission. NPSG.02.03.01: Critical Tests, Results and Values. Dec. 2009. http://www.jointcommission.org/AccredirationPrograms/ LaboratoryServices/Standards/09.-FAQs/NPSG/Communication/ NPSG.02.03.01/ Critical-tests-results-values.htm. (last accessed Mar. 19, 2010).
23. Clinical Laboratory Improvement Amendments of 1988 Final Rule (42 CFR Part 405). Fed Reg 57: 7001-7186, Feb. 1992.
24. Commission on Laboratory Accreditation, College of American Pathologists: Laboratory General Checklist-Questions Related to Reporting of Results Only, Mar. 2005. http://vvww.cap.org/apps/docs/padiology-reporting/ LabGeneralChecklist-Reporting.pdf (last accessed Mar. 19, 2010).
25. Singh H., et al.: Communication outcomes of critical imaging results in a computerized notification system. J Am Med Inform Assoc 14: 459-466, Jul.-Aug, 2007. Epub Apr. 25, 2007.
26. Singh H., et al.: Improving follow-up of abnormal cancer screens using electronic health records: Trust but verify test result communication. BMC Med Inform Decis Mak 9:29, Dec. 2009.
27. Valenstein P.N.: Notification of critical results: A College of American Pathologists Q-Probes study of 121 institutions. Arch Pathol Lab Med 132: 1862-1867, Dec. 2008.
28. Roy C.L., et al.: Patient safery concerns arising from test results that return after hospital discharge. Ann Intern Med 143: 121-128, Jul. 19. 2005.
29. Kuperman G.J., et al.: Improving response to critical laboratory results with automation: Results of a randomized controlled trial. J Am Med Inform Assoc 6: 512-522, Nov. Dec. 1999.
30. Kost G.J.: Critical limits for urgent clinician notification at US medical centers. JAMA 263: 704-707, Feb. 2, 1990.
31. Emancipator K.: Critical values: ASC-P practice parameter. American Society of Clinical Padiologists. Am J Clin Pathol 108: 247-253, Sep. 1997.
32. Huang E.C.: Critical diagnoses in surgical pathology: A retrospective single-institution study to monitor guidelines for communication of urgent results. Am J Surg Pathol 33:1098-1102, Jul. 2009.
33. Association of Directors of Anatomic and Surgical Pathology: Critical diagnoses (critical values) in anatomic pathology. Hum Pathol 37: 982-984, Aug. 2006. Epub Jun. 2, 2006.
34. American College of Radiology: ACR Practice Guideline for Communication of Diagnostic Imaging Findings. 2005 (Res. 11). http://www.acr.org/ SecondaryMainMenuCategories/quality-safety/guidelines/dx/comm-diag-rad.aspx (last accessed Mar. 19, 2010).
35. Sung S., et al.: Direct reporting of laboratory test results to patients by mail to enhance patient safety. V Gen Intern Med 21: 1075-1078, Oct. 2006.
36. Acccreditation Council for Graduate Medical Education (ACGME): Resident Services Menu: Resident Duty Hours Documents. http://vvww.acgme.org/acWebsite/ navPages/nav-residents.asp (last accessed Mar. 24, 2010).