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The Joint Commission recently issued one of its “Quick Safety” alerts on a topic near and dear to us: failure to close the loop on studies ordered (TJC 2019). Our many columns, listed below, highlight serious patient injuries occurring when significant test or imaging findings are not promptly conveyed to responsible physicians or to patients. There are many reasons, related to both human factors and system issues, that significant results “fall through the cracks”. Responsibility to ensure closing the loop is the responsibility of the ordering physician, the radiologist/imager (or lab for lab test results), the physician primarily responsible for management of the patient, and the patient him/herself.
The new Joint Commission Quick Safety alert (TJC 2019) begins with a case vignette in which a woman undergoes mammography that has suspicious findings. But these slip through the cracks until a year later, at which time her lesion had grown significantly, and she now required surgery, chemotherapy and radiation for advanced breast cancer.
Contributing factors included:
- Her PCP was not on the same electronic medical record (EMR) as the imaging center
- There were also front office changes
- As a result. the PCP missed the notification to follow up
- The patient was told that the radiologist would contact her if the results were abnormal; otherwise, it was safe to assume that things were normal
- Since the patient never received a follow-up call, she thought she was okay.
- The radiologist responsible for making follow-up calls worked from a printed list and had received only Page 1 of the month’s list; Page 2, which included the patient’s name, did not get transmitted to the radiologist.
The Joint Commission Quick Safety alert focuses on a tool to help reduce patient safety incidences during the diagnostic process. That tool, the Improving Diagnosis in Medicine Change Package, is the result of a collaboration between the Health Research & Educational Trust (HRET) Hospital Improvement Innovation Network (HIIN) and the Society to Improve Diagnosis in Medicine (SIDM), with contributions by patients and their families. They also link to the “Health IT Safe Practices for Closing the Loop. Mitigating Delayed, Missed, and Incorrect Diagnoses Related to Diagnostic Testing and Medication Changes Using Health IT” (ECRI 2018) that we discussed in our September 2018 What's New in the Patient Safety World column “ECRI Institute Partnership: Closing the Loop” and the SAFER guidelines (ONC 2016) that we’ve referenced in several columns.
Recommendations in this Quick Safety alert include:
- Identify workflows that are particularly vulnerable to mishandling of test results, and develop back-up procedures to ensure test results are received by someone responsible for the affected patient's care. These procedures should address handoffs between clinicians and care transitions between clinical settings.
- Establish consistent processes to ensure that test results are communicated to a clinician responsible for follow-up care.
- Notify patients of life-threatening test results through verbal means and ensure positive confirmation of receipt.
- Forward or escalate to an alternate responsible provider any abnormal test result that remains unacknowledged after a pre-specified time period.
- Ensure that test results are communicated to a back-up provider in a timely fashion in the event that the ordering provider is not available. The necessary timeliness is dependent on the significance of the test result.
- Optimize your organization’s health information technology (IT) capabilities to communicate test results. Health IT can be used to automate the abovementioned actions and help measure effectiveness.
- Improve your organization’s patient portal(s) to help patients access test results and better track their medical histories.
They note that, while many patients find the portals confusing and lacking important context for test results, there are some ways to improve them, including:
- Ensure the portal is accessible on both large-format computers and hand-held devices.
- Provide and promote patient access to EHRs, optimally including real time clinical notes and diagnostic testing results.
- Explain the test results directly in the portal.
- Provide patients easy access to support services as needed for action and follow up.
- Give patients personalized or contextual information to help them understand what to do with the results.
- Create consensus and standards on timing and best practices for the portal’s release of normal and abnormal test results.
However, the Quick Safety alert goes on to caution clinicians not to assume their patients will make use of online portals. It notes that some patients may be uncomfortable or unversed in online portals and would prefer direct person-to-person communication. Clinicians should not rely solely on the portals to communicate abnormal test results and contact their patients directly when action is necessary.
A few of our own additional recommendations:
- Never, ever, tell a patient they will be contacted if their results are abnormal. No news is not good news! They need to know when to expect the results and what to do if they have not been contacted about those results by that time.
- Ask your patient what their preferred method of receiving test results is, keeping in mind that there are certain test results you will want to convey to them verbally yourself (either face-to-face or by phone).
- Make sure you have a system (a “tickler” file) that alerts you to any test results you have not yet seen.
- Every imaging practice must have a system in place, in which they identify “significant” findings and have a way to ensure the patient is made aware of those findings. Many states may adopt the mandate we described in our November 26, 2019 Patient Safety Tip of the Week “Pennsylvania Law on Notifying Patients of Test Results”.
- Pay particular attention to high-risk scenarios, like tests pending at hospital discharge (or ER discharge) or tests pending as you go on vacation.
See also our other columns on communicating significant results:
TJC (The Joint Commission). Quick Safety 52: Advancing safety with closed-loop communication of test results. The Joint Commission 2019
“Improving Diagnosis in Medicine” Change Package
HRET (Health Research & Educational Trust). Improving Diagnosis in Medicine. Diagnostic Error Change Package. Health Research & Educational Trust. September 2018
Partnership for Health IT Patient Safety. Health IT Safe Practices for Closing the Loop. Mitigating Delayed, Missed, and Incorrect Diagnoses Related to Diagnostic Testing and Medication Changes Using Health IT. ECRI Institute 2018
ONC (Office of the National Coordinator for Health Information Technology). SAFER GUIDES—Safety Assurance Factors for EHR Resilience. Test Results Reporting and Follow-Up. ONC 2016; September 2016
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