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Press Start: Lead an Empowered Life as a Clinical Laboratorian

Hard to Meet National Patient Safety Goal

Published October 26, 2007 11:30 AM by Glen McDaniel
Several years ago, the Joint Commission instituted the National Patient Safety Goals (NPSG) which are revised on an annual basis.

The Patient goals are designed to improve patient care and increase safety largely because of reports that almost 100,000 patients die each year due to medical errors. One huge reason for errors agreed on by the Joint Commission, CAP and CLIA is a pervasive lack of clear communication. Joint Commission data from 1995 to 2004 indicates poor communication accounts for over 60 percent of sentinel events in hospitals. 

For the laboratory, communication includes the timely reporting of critical lab results. Many laboratorians do not understand this concept, however, and end up falling short of the standard or (equally bad) waste time and resources with overkill, doing way more than they need to.

The goal (Goal 2, specifically 2a and 2c) basically says laboratories (and other service providers like radiology, by the way) must "measure, assess and improve (if appropriate) the timeliness of reporting and timeliness of receipt of test results to a responsible caregiver." To ensure mutual understanding, the Joint Commission also requires "read back" (i.e., "results read back and verified") as documentation. Read back also applies, by the way, to verbal or telephone medical orders for obvious reasons. 

The concept seems logical and simple enough, but some labs define "critical" too liberally, so they have to call too many results. Critical means a result (whether a potassium or cardiac enzyme or CT scan) that is so abnormal it will negatively impact patient care/safety if no action is taken.

Do you call every high creatinine to dialysis, every low WBC to oncology, a glucose that's trending down from 600 every hour it is performed? Why?

Then, there is the misconception the result must be given directly to the ordering physician; again not true. The patient's nurse, or the charge nurse, or even any RN on the floor (as a lesser alternative) is OK. The most bizarre suggestion I have heard repeated often is the lab must verify that the physician gets the result (i.e., track the nurse's contact with the doctor) and track specifically how treatment has changed.

This particular NPSG is very logical and benefits patients, but as practiced in many laboratories, it is a clear example of misunderstanding causing way too much work and is the source of way too much drama. It's not that big of a deal.

1 comments

Actually, Glen, there is a little more to it. Joint Commission has muddied the waters by introducing the concept of "critical tests" and they want the TAT of both "critical results" and "critical tests" monitored. Even though these two concepts are totally different, they've merged them in a very confusing way into NPSG 2C.

For "critical results" they want to see the post-analytic TAT only (from result-to-call for lab). For "Critical tests" they want the overall TAT from order-to-report. And this TAT should be described in an organizational policy which is agreed to by  those ordering "critical tests" and the departments doing the testing.

Problem is they have sent mixed messages on how to define what a "critical test" is. While they say a critical test is one which requires a rapid TAT, they deliberately avoid using the term Stat---although that appears to be their intent. In addition their FAQs are full of confusing terminology that leave the impression organizations can define "critical tests" any way they want.

Since Stat abuse is so rampant in healthcare, many are afraid to define Critical tests as Stat tests---since they would then have to agree on TATs---especially for the pre-analytic process---and monitor them. Although labs have been monitoring their TATs for many years, nursing typically does not.

As a result of all this confusion, this particular patient safety goal has one of the highest rates of non-compliance.

These two articles help to clarify what NPSG 2C is about:

1)  Lab Focus-Issue 3,2007 has a brief but helpful article (found by searching www.jointcommission.com);

2) "Critical Test Reporting" in Aug 2007 issue of Clinical Laboratory News (found at www.aacc.org/AACC/publications/cln/2007/august/cover2_0807.htm). The MT(ASCP) who is Associate Director of Standards Interpretation for Joint Commission is interviewed in this article.

I'm surprised there hasn't been more discussion here in response to your posting several months ago. It would be interesting to here how different labs are doing with this.

Carol Edmisten, Quality Management - Quality Consultant March 30, 2008 8:44 PM
Bothell WA

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