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What’s New in the Patient Safety World
January 2020
The Joint Commission on Closing the Loop
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:
- May 1, 2007 “The
Missed Cancer”
- February 12, 2008 “More
on Tracking Test Results”
- October 13, 2009 “Slipping
Through the Cracks”
- July 2009 “Failure
to Inform Patients of Clinically Significant Outpatient Test Results”
- March 9, 2010 “Communication
of Urgent or Unexpected Radiology Findings”
- March 1, 2011 “Tests
Pending at Discharge”
- August 21, 2012 “More
on Missed Followup of Tests in Hospital”
- October 2, 2012 “Test
Results: Everyone’s Worst Nightmare”
- March 12, 2013 “More
on Communicating Test Results”
- October 2013 “New
AHRQ Toolkit: Improving Your Office Testing Process”
- January 2014 “Email
Alerts for Pending Test Results”
- July 2015 “Technology
to Avoid Delays in Follow-up of Significant Results”
- November 17, 2015 “Patient
Perspectives on Communication of Test Results”
- December 20, 2016 “End-of-Rotation
Transitions and Mortality”
- September 2018 “ECRI
Institute Partnership: Closing the Loop”
- September 24, 2019 “EHR-related
Malpractice Claims”
- November 26, 2019 “Pennsylvania
Law on Notifying Patients of Test Results”
References:
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
https://www.improvediagnosis.org/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
https://www.ecri.org/Resources/HIT/Closing_Loop/Closing_the_Loop_Toolkit.pdf
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
https://www.healthit.gov/sites/default/files/safer_test_results_reporting.pdf
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