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LABORATORY POLICY AND PROCEDURE
TITLE/SUBJECT:
FILE NUMBER:
ASSIGNED MANUAL:
ORIGINATION DATE:
EFFECTIVE DATE:
DISTRIBUTION:
Critical Test/ Critical Result Reporting
QA 030.05
Quality Assurance
11/31/2006
01/07/2015
All of Saint Michael’s Hospital Laboratories
PRINCIPLE/PURPOSE:
Ministry Saint Michael’s Hospital and Ministry Medical Group-Central Region will
communicate the results of tests considered critical to patient care to the responsible
licensed caregiver in a timely and reliable manner according to established guidelines.
1.0
2.0
3.0
4.0
To prevent delays in taking actions in responding to critical tests and critical
results that may have the potential for serious harm to the patient.
To define critical tests and critical results.
To establish a communication processes with the responsible licensed caregiver
To develop a system for measuring and assessing the timeliness of reporting
critical tests and critical results with the goal of ensuring timely reporting.
DEFINITIONS:
Critical Test Result: Those test results that fall significantly outside the normal range
and/or may represent life-threatening values, even from routine tests and that require
rapid communication of results to the responsible caregiver. A delay in taking action to
respond to the result may result in a serious adverse outcome for the patient. In addition,
panic/alert/critical results as defined by reference laboratories will be used for tests
completed outside the organization. Critical test results are defined by the performing
department in collaboration with Ministry Saint Michael’s Hospital and Ministry Medical
Group-Central Region medical staff.
Timeliness of reporting critical test results: The acceptable length of time
between completion of the test (identifying the critical result) and receipt by the
responsible licensed caregiver will be within one (1) hour unless:
a) The provider documents specific diagnostic notification range values in the medical
record, or
b) The critical value is improved from a previous value and the provider is aware of the
previous value.
QA030.05 CRITICAL TEST&CRITICAL RESULT REPORTING 3rd Edition
Rev: 1/7/2015
Authorized Staff: The following health care professionals may act as authorized staff:
Registered Nurses, Licensed Practical Nurses, Medical Assistants, and Respiratory
Practitioners.
Responsible Licensed Caregiver: Physicians, Physician Assistants, Nurse Practitioners,
and Advanced Practice Nurse Prescribers.
Subsequent / Sequential critical results: Clinical judgment, based on patient status,
determines if these results are to be communicated to the physician as a critical result.
Communicating critical tests/ critical results to the responsible licensed caregiver
It is acceptable for results of critical tests and critical results to be communicated to
authorized staff members who would then be accountable for communication to the
responsible licensed caregiver. When the patient’s responsible licensed caregiver is not
available within the time frames, the information will be reported to an alternate
responsible licensed caregiver.
In the event that a patient’s provider cannot be reached and does not respond to a
call/page, the call will be repeated in 15 minutes. If successful contact cannot be
established, the on-call physician will be paged. If no response, follow the chain of
command.
To ensure accurate communication, telephone reporting of results from critical tests
(normal or abnormal) or critical results, requires a “read-back” of the information by the
person receiving the test result. The person receiving the test result will write down the
result (if possible) and read it back to the person providing the result. The person
providing the test result will confirm the information was read back. For Ministry Saint
Michael’s Hospital Laboratory, the read-back process is documented in the medical
record.
Results from critical tests and critical results must be called after verification in the
laboratory. Results are called to authorized staff or the responsible licensed caregiver.
Results on patients designated as “temp location” or Operating Room will be sent directly
to the O.R. printer. Additionally, call the O.R. to notify that it’s printed.
Measure and assess timeliness of reporting critical tests/ critical results
Data is collected by the appropriate departments based on concurrent observation or
retrospective medical record review and sent to the Quality Department for compilation
and creation of monthly and quarterly reports. Data measuring the timeliness of reporting
critical test results is discussed at various meetings, including the Joint Commission Core
Team. Time frames are analyzed to determine whether improvements in timeliness of
reporting are needed. If improvements are needed, action plans will be created.
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QA030.05 CRITICAL TEST&CRITICAL RESULT REPORTING 3rd Edition
Rev: 1/7/2015
Critical Tests
• OR frozen section
• See attached chart for specific critical lab values
Special circumstances
Tests may be done in departments (e.g. ICU or WIC) where provisions have been made
by the physician provider for the clinical management of critical results, such as a signed
order set for electrolyte replacement or glucose management via insulin drop titration.
These tests may have critical results, but the nurse, following the appropriate parameters
as set forth in the respective orders set, will respond on behalf of the provider.
Specific Examples for Critical Laboratory Results and Critical Tests.
1.0
Calling of Critical Laboratory Values and critical tests to caregivers or designees
Critical Values and other laboratory results called to health care staff or designees
must be documented in the MEDITECH system and be done within time frames
established.
Each laboratory has developed a list of results to be called to physicians or other
clinical personnel responsible for patient care. In addition, critical values as
defined by reference laboratories will be called to afore mentioned.
The following is the format that should be used for calling /documenting all
results:
Use canned text "LCALL" to document that you called a critical value listed on
the attached Critical Value List to someone other than a provider:
Called [] [now] [today] [user].
Will you be able to tell the provider these critical results
immediately? []
Results read-back by caregiver with assurance that critical
results will be delivered to the provider immediately.
EXAMPLE: Called LK, RN 1402 01/07/06 JS
Will you be able to tell the provider these critical results
immediately? Y
Results read-back by caregiver with assurance that critical
results will be delivered to the provider immediately.
Use canned text "LCALLMD" to document that you called a critical value listed
on the attached Critical Value List directly to the provider:
Called [] [now] [today] [user]
Results read-back by provider.
EXAMPLE: Called TJM,MD 1402 01/07/06 KS
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QA030.05 CRITICAL TEST&CRITICAL RESULT REPORTING 3rd Edition
Rev: 1/7/2015
Results read-back by provider.
Use canned text “CALL” to document that you called a result to a licensed
caregiver that is not deemed as a critical value:
Called [] [now] [today] [user].
Results read-back by caregiver.
Please report these results to the provider.
EXAMPLE: “Called MT, RN 0650 01/31/08 MW”
Results read-back by caregiver.
Please report these results to the provider
2.0
Result Read Back Policy
This process will be utilized in the taking of verbal or telephone orders and the
calling of results to providers.
All diagnostic tests including laboratory tests and other diagnostic tests to include
any test/ result which require an urgent response must be read back by the person
receiving the results.
Calling of test results must be documented in the MEDITECH system as
described in the calling policy. In addition it must be indicated that the results
were read back by the person receiving the results.
Example:
CALLED MT, RN 0650 01/31/06 MW
Will you be able to tell the provider these critical results
immediately? Y
Results read-back by caregiver with assurance that critical
results will be delivered to the provider immediately.
SAFETY PRECAUTIONS:
Follow procedures and precautions described in the Saint Michael's Hospital Infection
Control and Hazard Communication manuals, as well as the Saint Michael's Hospital
Chemical Hygiene Plan. Refer to the MSDS for reagent-specific handling guidelines.
ATTACHMENTS:
Critical Value Chart
REFERENCES:
The Joint Commission - National Patient Safety Goals
Ministry Health Care Critical Test Reporting Policy – MSMH and MMGCR (PHY-037)
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QA030.05 CRITICAL TEST&CRITICAL RESULT REPORTING 3rd Edition
Rev: 1/7/2015
ORIGINATING DEPARTMENT/SECTION:
Saint Michael’s Hospital Laboratory
AUTHOR AND DATE:
Rod Hoeth, MT-ASCP Laboratory Supervisor 11/30/2006
REVISED BY AND DATE:
Rod Hoeth, MT-ASCP Laboratory Supervisor 02/16/2009
Dawn Finch- Laboratory Supervisor 08/10/2009
Michelle O’Connell, MT (ASCP) – Quality Improvement Coordinator 01/18/2010
Michelle O’Connell, MT (ASCP) – Quality Improvement Coordinator
Edits include removal of non-lab related information (ie: Diagnostic Imaging Criticals)
January 7, 2015
APPROVAL:
___________________________________________________________
Dawn Finch, MT (ASCP) – Director of Laboratory Services
___________________________________________________________
Jason Heese, MD – Medical Director of Laboratory Services
S:\Lab\Lab Manuals\Quality\CRITICAL TEST&CRITICAL RESULT REPORTING 3rd Edition.doc
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QA030.05 CRITICAL TEST&CRITICAL RESULT REPORTING 3rd Edition
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