Critical Results Reporting Procedure

Institution:
/ Version: 1.0 / Date: / Number of pages: 3 / Name of procedure:
Critical Results Reporting Procedure / ID Code:Ap 12
QM chapter: 7
Critical Results Reporting / ID Code:
Ap 12
Topic & Purpose:
Explains how to report critical results / Review Period:
1 year
Location: / Distribution:
Version number:
V 1.0 / Annex:
None
Written by:
Name(s), Date(s) and Signature(s) of the Author(s)
Reviewed by:
Name(s), Date(s) and Signature(s)
Authorized by:
Name, Date and Signature
Replaces the version:
Not applicable (1st version)
Changes to the last authorized version:
Not applicable (1st version)

Critical Results Reporting Procedure

Application

Objective

Definitions

References

Responsibilities

Operating Mode

Application

This procedure ensures the proper reporting of critical laboratory test results.

Objective

This procedure has been developed to explain how to report critical results.

Definitions

Critical results:A laboratory result that suggests the patient is in imminent danger unless appropriate therapy is initiated promptly (Lundberg, 1972).

References

Lundberg GD. When to panic over abnormal values. Med. Lab.

Obs., 1972, 4:47-54.

Responsibilities

Authorized personnelare responsible for ensuring critical results are reported according to this procedure.

Operating Mode

NOTE: All critical results should be called to anauthorized health care provider immediately.

1. The laboratory management should recheck the critical result if possible.

2. For all critical results, laboratory staff will document in a special logbookXXX:

the critical result value;
the reporting and verification of “read back” of these values to the appropriate health care provider.

The documentation will include:

the name of the laboratory individual reporting the critical results;
the first initial, last name and professional title of the health careprovider who was notified of the critical results;
the date and time at which the notified individual “read back” the critical results.

3. Any problems, including refusal to accept the results, that may be encountered in notifying in a timely manner should be noted.

4. To report a critical result:

a) Call the patient’s appropriate location (e.g. clinic).

NOTE: If a patient has more than one critical result, all critical results may be conveyed during the same call.

b) Identify yourself as clinical laboratory personnel and ask to speak to a authorized health care provider.

c) Inform the authorized health care provider that you are reporting a critical laboratory result (or results) on patient (identify patient by last and first name and Medical Record Number).

d) Upon completion of the critical result notification, ask the authorized health care provider toverbally read back ALL of the reported critical result(s) and to properly identify him/herself (at minimum with the first initial of their name and their entire last name), including his/her professional title.

5. After the call the original laboratory’s report (and charts) will be printed, signed byauthorized personnel,and appropriately stored.

6. The laboratory, on a monthly basis, will measure, assess, and, if appropriate, take action to improve the timeliness of reporting, and the timeliness of receipt byauthorized health care providers, of critical test results.

Supervisor(s) or authorized designees will periodically print out a Critical Results Report in order to measure and assess that all critical results were called and read back.
Upon completion of the assessment the supervisor will complete and forward a Critical Results Assessment Form to the Quality Manager.