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Faurø KK, Antonsen S, Nybo M. Critical test result management at Danish hospital laboratories: a national survey. Scand J Clin Lab Invest 2024; 84:174-182. [PMID: 38648389 DOI: 10.1080/00365513.2024.2343906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Accepted: 04/12/2024] [Indexed: 04/25/2024]
Abstract
Critical test results in clinical laboratories are crucial for timely patient care, serving as indicators of potentially life-threatening conditions. Despite their importance, a notable heterogeneity in management practices exists globally. This study investigates the current practices of managing critical results at Danish clinical biochemistry laboratories and identifies areas prone for improvement. A comprehensive online survey was distributed to all 21 Danish clinical biochemistry laboratories regarding their critical result management, including documentation practices, critical limit selection, and quality assurance measures. A total of 17 laboratories (81%) responded. The answers revealed a generally uniform approach to managing critical results, with all laboratories having 24-h reporting, local instructions and using the telephone as communication channel. However, variations were noted in documentation practices and critical limit selection. Notably, 23.5% of the laboratories reported that one out of every ten critical results was not reported, indicating a significant risk of delayed critical results. This is further complicated by the limited use of predefined timeframes for reporting and also, only few laboratories actively monitored response times. The findings emphasize the need for more standardized documentation and evaluation practices to align with international standards and to enhance patient safety. While the laboratories showed a commitment to standardized procedures, the study emphasizes the necessity of a National or Nordic guideline to supplement the ISO 15189:2022. This study is a step towards optimizing critical result management, not only in Danish clinical biochemistry laboratories but also across various laboratory specialties, thereby improving overall laboratory quality, efficiency, and patient safety.
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Affiliation(s)
- Kaja Kastberg Faurø
- Department of Clinical Biochemistry, Odense University Hospital, Odense, Denmark
| | - Steen Antonsen
- Department of Clinical Biochemistry, Odense University Hospital Svendborg, Svendborg, Denmark
| | - Mads Nybo
- Department of Clinical Biochemistry, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
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2
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Kost GJ, Dohner J, Liu J, Ramos D, Haider N, Thalladi V. Web-accessible critical limits and critical values for urgent clinician notification. Clin Chem Lab Med 2024; 0:cclm-2024-0117. [PMID: 38641917 DOI: 10.1515/cclm-2024-0117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Accepted: 04/05/2024] [Indexed: 04/21/2024]
Abstract
OBJECTIVES To survey the World Wide Web for critical limits/critical values, assess changes in quantitative low/high thresholds since 1990-93, streamline urgent notification practices, and promote global accessibility. METHODS We identified Web-posted lists of critical limits/values at university hospitals. We compared 2023 to 1990-93 archived notification thresholds. RESULTS We found critical notification lists for 26 university hospitals. Laboratory disciplines ranged widely (1-10). The median number of tests was 62 (range 21-116); several posted policies. The breadth of listings increased. Statistically significant differences in 2023 vs. 1990 critical limits were observed for blood gas (pO2, pCO2), chemistry (glucose, calcium, magnesium), and hematology (hemoglobin, platelets, PTT, WBC) tests, and for newborn glucose, potassium, pO2, and hematocrit. Twenty hospitals listed ionized calcium critical limits, which have not changed. Fourteen listed troponin (6), troponin I (3), hs-TnI (3), or troponin T (2). Qualitative critical values expanded across disciplines, encompassing anatomic/surgical pathology. Bioterrorism agents were listed frequently, as were contagious pathogens, although only three hospitals listed COVID-19. Only one notification list detailed point-of-care tests. Two children's hospital lists were Web-accessible. CONCLUSIONS Urgent notifications should focus on life-threatening conditions. We recommend that hospital staff evaluate changes over the past three decades for clinical impact. Notification lists expanded, especially qualitative tests, suggesting that automation might improve efficiency. Sharing notification lists and policies on the Web will improve accessibility. If not dependent on the limited scope of secondary sources, artificial intelligence could enhance knowledge of urgent notification and critical care practices in the 21st Century.
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Affiliation(s)
- Gerald J Kost
- Department of Pathology and Laboratory Medicine, School of Medicine, Davis, CA, USA
- Point-of-Care Testing Center for Teaching and Research (POCT•CTR), Davis, CA, USA
- CEO, Knowledge Optimization, Davis, CA, USA
| | | | - Janet Liu
- University of California, Davis, CA, USA
| | - Dean Ramos
- University of California, Davis, CA, USA
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3
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Montero-San-Martín B, Oliver P, Fernandez-Calle P, Sánchez-Pascuala Callau JJ, Díaz Almirón M, Alcaide Martín MJ, Fernández-Puntero B, Duque Alcorta M, Valero Recio JM, Martín Quirós A, de Ceano-Vivas la Calle M, Martín Sánchez J, Rivas Becerra B, Vega Cabrera C, Melgosa Hijosa M, Buno Soto A. Laboratory interpretative comments and guidance: clinical and operative outcomes on moderate to severe hyponatraemia patient management. J Clin Pathol 2023; 76:116-120. [PMID: 34518360 DOI: 10.1136/jclinpath-2021-207611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 08/29/2021] [Indexed: 01/26/2023]
Abstract
AIMS Hyponatraemia is the most common body fluid disorders but often goes unnoticed. Our laboratory incorporated a standardised procedure to help clinicians detect moderate/severe hyponatraemia. The study aims were to evaluate the outcomes on patient care and clinicians' satisfaction. METHODS The study, observational and retrospective, included 1839 cases, adult and paediatric patients, with sodium concentration <130 mmol/L. The procedure consisted of interpretative comments in the emergency and core laboratories report and the point-of-care testing blood gas network report. We evaluated hyponatraemia length in two equal periods: before and after the implementation. We conducted a survey addressed to the staff of the clinical settings involved to know their satisfaction. RESULTS The median hyponatraemia length decreased significantly from 4.95 hours (2.08-16.57) in the first period to 2.17 hours (1.06-5.39) in the second period. The lack of hyponatraemia patients follow-up was significantly less after the procedure implementation. The survey was answered by 92 (60 senior specialists and 32 residents) out of 110 clinicians surveyed. Ninety of them (98%) answered positively. CONCLUSIONS We have demonstrated the reduction in the time for diagnosing and management by physicians, the higher uniformity in the time required to solve hyponatraemia episodes following our laboratory procedure and the clinicians' satisfaction.
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Affiliation(s)
| | - Paloma Oliver
- Department of Laboratory Medicine, La Paz University Hospital, Madrid, Spain
| | | | | | | | | | | | - Marta Duque Alcorta
- Department of Laboratory Medicine, La Paz University Hospital, Madrid, Spain
| | | | | | | | | | | | | | | | - Antonio Buno Soto
- Department of Laboratory Medicine, La Paz University Hospital, Madrid, Spain
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4
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Laguna J, Macias-Muñoz L, Bedini JL, Rico N. Notification of biochemistry critical results and its clinical impact on outpatient care: experience in a Spanish tertiary hospital. Clin Chem Lab Med 2021; 59:1777-1783. [PMID: 34271598 DOI: 10.1515/cclm-2021-0495] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 06/28/2021] [Indexed: 11/15/2022]
Abstract
OBJECTIVES The communication of critical results (CR) is considered an essential role in clinical laboratories to ensure patient safety. This is especially relevant to outpatients, who are non-hospitalized and more difficult to locate. In our laboratory, there is a specific protocol for CR management that sets up the communication pathway to adequately provide these results to clinicians. The aim of this study is to evaluate the impact of CR reporting on outpatient care. METHODS This is a retrospective study focused on CR for biochemistry parameters in a clinical laboratory of a Spanish tertiary hospital during 2019. A total of 156 CR were determined and properly provided to clinicians. We collected CR, age, gender, and the requesting department. We also collected the medical action data resulting from the communication of the CR. RESULTS Seventy-six outpatients (49%) were properly treated because of effective CR communication. Hypoglycemia was the most frequent event (33%), however, the greatest clinical impact was observed for patients with hyponatremia (100%), hyperkalemia (62%), hypokalemia (60%), and hypercalcemia (57%). Based on these findings, we evaluated new glucose alert thresholds depending on whether or not the outpatient was diabetic (1.7 and 2.2 mmol/L, respectively). Based on these new thresholds, we established a CR reporting protocol with 69% effectiveness in outpatients. CONCLUSIONS We demonstrate that CR communication in outpatients has a significant clinical impact. To increase the effectiveness of the CR reporting protocol, we propose to adjust alert thresholds according to pathology, department, and patient population.
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Affiliation(s)
- Javier Laguna
- Biochemistry and Molecular Genetics Department, Biomedical Diagnostic Centre, Hospital Clínic, Barcelona, Spain
| | - Laura Macias-Muñoz
- Biochemistry and Molecular Genetics Department, Biomedical Diagnostic Centre, Hospital Clínic, Barcelona, Spain
| | - José Luis Bedini
- CORE Laboratory, Biochemistry and Molecular Genetics Department, Biomedical Diagnostic Centre, Hospital Clínic, Barcelona, Spain
| | - Naira Rico
- CORE Laboratory, Biochemistry and Molecular Genetics Department, Biomedical Diagnostic Centre, Hospital Clínic, Barcelona, Spain
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5
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Karin A, Kulasingam V, Chartier LB, Ejumudo A, Wolff T, Brinc D. Recurring Critical Results and Their Impact on the Volume of Critical Calls at a Tertiary Care Center. J Appl Lab Med 2021; 6:962-968. [PMID: 33582795 DOI: 10.1093/jalm/jfab001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 01/04/2021] [Indexed: 11/13/2022]
Abstract
BACKGROUND When a test result is critically abnormal, laboratories notify the responsible caregivers immediately, usually with a phone call. If the same test was ordered repeatedly, our institution has a policy of not notifying the caregiver if the previous result was also critical and within 24 h. We compared our policy with those of several different laboratories in North America and estimated the impact of changing our current policy to calling for all critical results, regardless of the time interval. METHODS Several North American laboratories (n = 15) were surveyed regarding their critical result notification policy. For our institution, we performed a retrospective analysis focusing on critical values in a 5-month period for common chemistry tests. We estimated the effect on volume of calls and the impact on workload with regard to changing the critical result notification policy and critical thresholds. RESULTS A majority of surveyed laboratories had some form of restriction for calling about recurring critical results. In our institution, removing the restrictions would increase the average number of daily calls by 11%-155%, depending on the analyte. The choice of critical thresholds also has an effect on the number of calls, and the effect depends on the analyte and the threshold chosen. CONCLUSIONS Guidelines do not specify how recurring critical results should be communicated. Depending on the institutional resources, some laboratories call only the first critical result for one or more tests if certain criteria are met. Modification of these policies can lead to significant changes in the volume of calls made by the laboratory and can have numerous impacts related to workload, logistics, and patient care.
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Affiliation(s)
- Amir Karin
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Canada
| | - Vathany Kulasingam
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Canada.,Department of Clinical Biochemistry, University Health Network, Toronto, Canada
| | - Lucas B Chartier
- Department of Emergency Medicine, University Health Network, Toronto, Canada
| | - Angela Ejumudo
- Department of Clinical Biochemistry, University Health Network, Toronto, Canada
| | - Talya Wolff
- Department of Clinical Biochemistry, University Health Network, Toronto, Canada
| | - Davor Brinc
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Canada.,Department of Clinical Biochemistry, University Health Network, Toronto, Canada
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Elbagir S, Elshafie AI, Elagib EM, Mohammed NA, Aledrissy MIE, Sohrabian A, Nur MAM, Svenungsson E, Gunnarsson I, Rönnelid J. Sudanese and Swedish patients with systemic lupus erythematosus: immunological and clinical comparisons. Rheumatology (Oxford) 2020; 59:968-978. [PMID: 31411331 PMCID: PMC7188463 DOI: 10.1093/rheumatology/kez323] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Revised: 07/02/2019] [Indexed: 12/31/2022] Open
Abstract
Objective SLE is known to have an aggressive phenotype in black populations, but data from African cohorts are largely lacking. We therefore compared immunological and clinical profiles between Sudanese and Swedish patients using similar tools. Methods Consecutive SLE patients from Sudan (n = 115) and Sweden (n = 340) and from 106 Sudanese and 318 Swedish age- and sex-matched controls were included. All patients fulfilled the 1982 ACR classification criteria for SLE. Ten ANA-associated specificities and C1q-binding immune complexes (CICs) were measured. Cut-offs were established based on Sudanese and Swedish controls, respectively. Disease activity was measured with a modified SLEDAI and organ damage with the SLICC Damage Index. In a nested case–control design, Swedish and Sudanese patients were matched for age and disease duration. Results Females constituted 95.6% and 88.1% of Sudanese and Swedish patients, respectively (P = 0.02), with younger age at inclusion (33 vs 47.7 years; P < 0.0001) and shorter disease duration (5 vs 14 years; P < 0.0001) among Sudanese patients. Anti-Sm antibodies were more frequent in Sudanese patients, whereas anti-dsDNA, anti-histone and CICs were higher in Swedish patients. In the matched analyses, there was a trend for higher SLEDAI among Swedes. However, Sudanese patients had more damage, solely attributed to high frequencies of cranial/peripheral neuropathy and diabetes. Conclusion While anti-Sm is more common in Sudan than in Sweden, the opposite is found for anti-dsDNA. Sudanese patients had higher damage scores, mainly because of neuropathy and diabetes. Sudanese patients were younger, with a shorter SLE duration, possibly indicating a more severe disease course with impact on survival rates.
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Affiliation(s)
- Sahwa Elbagir
- Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
| | - Amir I Elshafie
- Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
| | | | | | | | - Azita Sohrabian
- Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
| | - Musa A M Nur
- Rheumatology Unit, Alribat University Hospital, Khartoum, Sudan
| | - Elisabet Svenungsson
- Division of Rheumatology, Department of Medicine, Solna, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Iva Gunnarsson
- Division of Rheumatology, Department of Medicine, Solna, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Johan Rönnelid
- Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
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Li R, Wang T, Gong L, Dong J, Xiao N, Yang X, Zhu D, Zhao Z. Enhance the effectiveness of clinical laboratory critical values initiative notification by implementing a closed-loop system: A five-year retrospective observational study. J Clin Lab Anal 2019; 34:e23038. [PMID: 31531906 PMCID: PMC7031628 DOI: 10.1002/jcla.23038] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Revised: 08/21/2019] [Accepted: 08/23/2019] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Accurate and timely clinical laboratory critical values notification are crucial steps in supporting effective clinical decision making, thereby improving patient safety. METHODS A closed-loop laboratory critical value notification system was developed by a multidisciplinary team of clinicians, laboratorians, administrators, and information technology experts. All the laboratory critical values that occurred at Beijing Tsinghua Changgung Hospital (BTCH, Beijing, China) from 2015 to 2019 were analyzed and studied retrospectively. RESULTS The total number (ratio) of institutional laboratory critical values to all reported items at BTCH from 2015 to 2019 was 38 020/7 706 962 (0.49%). Percentage distribution points of critical value boundaries based on patients' test reports are 0.007% ~ 6.04% for low boundaries and 71.70% ~ 99.99% for high boundaries. After the intervention, the timely notification ratio, notification receipt ratio, and timely notification receipt ratio of critical values of ED, IPD, and total patients had increased, with a significant difference (P < .001). Five quality indicators, such as notification ratio, timely notification ratio, notification receipt ratio, timely notification receipt ratio, and clinician response ratio over a 5-year period, were 100%, 94%, 97%, 92%, and 99%, respectively. CONCLUSIONS We enhanced the effectiveness of clinical laboratory critical values initiative notification by implementing a closed-loop system and intervening. Clinical critical values and quality indicators should be analyzed and monitored to avoid adversely affecting patient care.
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Affiliation(s)
- Runqing Li
- Laboratory Medicine Department, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Tengjiao Wang
- Laboratory Medicine Department, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Lijun Gong
- Laboratory Medicine Department, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Jingxiao Dong
- Laboratory Medicine Department, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Nan Xiao
- Laboratory Medicine Department, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Xiaohuan Yang
- Laboratory Medicine Department, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Dong Zhu
- Laboratory Medicine Department, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Zhipeng Zhao
- Laboratory Medicine Department, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
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8
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Delgado Rodríguez JA, Pastor García MI, Gómez Cobo C, Pons Más AR, Llompart Alabern I, Bauça JM. Assessment of a laboratory critical risk result notification protocol in a tertiary care hospital and their use in clinical decision making. Biochem Med (Zagreb) 2019; 29:030703. [PMID: 31379461 PMCID: PMC6610674 DOI: 10.11613/bm.2019.030703] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Accepted: 05/27/2019] [Indexed: 12/21/2022] Open
Abstract
Introduction Communication of laboratory critical risk results is essential for patient safety, as it allows early decision making. Our aims were: 1) to retrospectively evaluate the current protocol for telephone notification of critical risk results in terms of rates, efficiency and recipient satisfaction, 2) to assess their use in clinical decision making and 3) to suggest alternative tools for a better assessment of notification protocols. Materials and methods The biochemical critical risk result notifications reported during 12 months by routine and STAT laboratories in a tertiary care hospital were reviewed. Total number of reports, time for the notification and main magnitudes with critical risk results were calculated. The use of notifications in clinical decision making was assessed by reviewing medical records. Satisfaction with the notification protocol was assessed through an online questionnaire to requesting physicians and nurses. Results Critical result was yielded by 0.1% of total laboratory tests. Median time for notification was 3.2 min (STAT) and 16.9 min (routine). The magnitudes with a greater number of critical results were glucose and potassium for routine analyses, and troponin, sodium for STAT. Most notifications were not reflected in the medical records. Overall mean satisfaction with the protocol was 4.2/5. Conclusion The results obtained indicate that the current protocol is appropriate. Nevertheless, there are some limitations that hamper the evaluation of the impact on clinical decision making. Alternatives were proposed for a proper and precise evaluation.
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Affiliation(s)
| | | | - Cristina Gómez Cobo
- Department of Laboratory Medicine, Hospital Universitari Son Espases, Palma, Spain
| | - Antonia R Pons Más
- Department of Laboratory Medicine, Hospital Universitari Son Espases, Palma, Spain
| | | | - Josep Miquel Bauça
- Department of Laboratory Medicine, Hospital Universitari Son Espases, Palma, Spain.,Instituto de Investigación Sanitaria de las Islas Baleares, Spain
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Tan EH, Yang Z, Li Y, Metz MP, Loh TP. Outcome-Based Critical Result Thresholds in the Adult Patient Population. Am J Clin Pathol 2019; 152:177-184. [PMID: 31067292 DOI: 10.1093/ajcp/aqz026] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
OBJECTIVES To derive outcome-based critical result thresholds in the adult patient population. METHODS We extracted deidentified laboratory results and outcomes (death or discharged) of patients 18 years and older from the Medical Information Mart for Intensive Care database. The lower and upper critical result thresholds were obtained from the nearest minimum and maximum laboratory values, which corresponded to predicted probability of death at 90%. RESULTS The critical value thresholds were sodium (<123, >153 mmol/L), potassium (<2.2, >6.6 mmol/L), bicarbonate (<15, >49 mmol/L), chloride (<82, >121 mmol/L), urea (>20 mmol/L), creatinine (>1,052 μmol/L), glucose (<1.5, >23.8 mmol/L), total calcium (<1.62, >2.95 mmol/L), magnesium (<0.37, >1.48 mmol/L), phosphate (<0.19, >2.52 mmol/L), pH (<7.22, >7.57), lactate (>5.0 mmol/L), hemoglobin (<4.6 g/dL), WBCs (>32 × 103/μL), prothrombin time (>90 seconds), and international normalized ratio (>10). CONCLUSIONS The indirect approach described in this study is a pragmatic way to obtain threshold values that are clinically and operationally meaningful.
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Affiliation(s)
- Eng Hooi Tan
- Saw Swee Hock School of Public Health, National University Hospital, Singapore
| | - Zhutian Yang
- School of Electrical and Electronic Engineering, Nanyang Technological University, Singapore
| | - Yingda Li
- Department of Industrial Systems Engineering and Management, National University Hospital, Singapore
| | - Michael P Metz
- SA Pathology, The Women’s & Children’s Hospital, Adelaide, Australia
| | - Tze Ping Loh
- Biomedical Institution for Global Health and Technology, National University Hospital, Singapore
- Department of Laboratory Medicine, National University Hospital, Singapore
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10
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Yang D, Cai Q, Qi X, Xu L, Zhou Y. An evaluation of adult critical result policies in haematology in a teaching hospital in China. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:47. [PMID: 30906751 DOI: 10.21037/atm.2019.01.16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Critical result (CR) reporting is one of the core policies in China, yet it varies in different hospitals. In addition, few reports of the evaluation of CR policies have been published. This study aimed to evaluate the adult CR policies for haematology in a teaching hospital. Methods The consistency was compared between CR policies in a tertiary hospital in China and the current standards, consensuses and literature. The incidences for the alert thresholds of white blood cells (WBC), haemoglobin (HgB), and platelets (PLT) and the turn-around time (TAT) for different phases of CR reporting in 2017 were investigated. On-site observation of the staff was used to assess CR implementation and compliance with CR policies. Results The clauses of adult CR policies in haematology were consistent with the requirements in the standards, consensuses and literature, and the CR items and alert thresholds were within the range reported in the literature. CRs in haematology were dominated by lower thresholds. The incidences of alerts due to WBC, HgB, and PLT levels were 37.5, 18.0 and 37.0 times/day, respectively. A total of 150 cases of CR implementation were observed on-site, and the procedures followed by the staff were consistent with the requirements of the polices. The TAT medians for CR verification in the outpatient, emergency and inpatient departments were ≤6 min. Conclusions The consistency and implementation of CR policies were both good, which ensures patient safety.
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Affiliation(s)
- Dagan Yang
- Department of Laboratory Medicine, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou 310003, China
| | - Qian Cai
- School of Nursing, Zhejiang Chinese Medical University, Hangzhou 310053, China
| | - Xinglun Qi
- Department of Laboratory Medicine, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou 310003, China
| | - Lili Xu
- Department of Laboratory Medicine, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou 310003, China
| | - Yunxian Zhou
- School of Nursing, Zhejiang Chinese Medical University, Hangzhou 310053, China
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11
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Piva E, Sciacovelli L, Pelloso M, Plebani M. Performance specifications of critical results management. Clin Biochem 2017; 50:617-621. [DOI: 10.1016/j.clinbiochem.2017.05.010] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2017] [Revised: 05/15/2017] [Accepted: 05/15/2017] [Indexed: 11/27/2022]
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12
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Reese EM, Nelson RC, Flegel WA, Byrne KM, Booth GS. Critical Value Reporting in Transfusion Medicine: A Survey of Communication Practices in US Facilities. Am J Clin Pathol 2017; 147:492-499. [PMID: 28371931 PMCID: PMC5848379 DOI: 10.1093/ajcp/aqx025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES While critical value procedures have been adopted in most areas of the clinical laboratory, their use in transfusion medicine has not been reviewed in detail. The results of this study present a comprehensive overview of critical value reporting and communication practices in transfusion medicine in the United States. METHODS A web-based survey was developed to collect data on the prevalence of critical value procedures and practices of communicating results. The survey was distributed via email to US hospital-based blood banks. RESULTS Of 123 facilities surveyed, 84 (68.3%) blood banks had a critical value procedure. From a panel of 23 common blood bank results, nine results were selected by more than 70% of facilities as either a critical value or requiring rapid communication as defined by an alternate procedure. CONCLUSIONS There was overlap among results communicated by facilities with and without a critical value procedure. The most frequently communicated results, such as incompatible crossmatch for RBC units issued uncrossmatched, delay in finding compatible blood due to a clinically significant antibody, and transfusion reaction evaluation suggestive of a serious adverse event, addressed scenarios associated with the leading reported causes of transfusion-related fatalities.
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Affiliation(s)
- Erika M. Reese
- From the Department of Transfusion Medicine, NIH Clinical Center, National Institutes of Health, Bethesda, MD
- Laboratories of Pathology, University of Maryland Medical Center, Baltimore
| | - Randin C. Nelson
- From the Department of Transfusion Medicine, NIH Clinical Center, National Institutes of Health, Bethesda, MD
- Department of Pathology, Staten Island University Hospital, Staten Island, NY
| | - Willy A. Flegel
- From the Department of Transfusion Medicine, NIH Clinical Center, National Institutes of Health, Bethesda, MD
| | - Karen M. Byrne
- From the Department of Transfusion Medicine, NIH Clinical Center, National Institutes of Health, Bethesda, MD
| | - Garrett S. Booth
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, TN
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Campbell CA, Georgiou A, Westbrook JI, Horvath AR. What Alert Thresholds Should Be Used to Identify Critical Risk Results: A Systematic Review of the Evidence. Clin Chem 2016; 62:1445-1457. [DOI: 10.1373/clinchem.2016.260638] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2016] [Accepted: 07/18/2016] [Indexed: 11/06/2022]
Abstract
Abstract
BACKGROUND
Pathology laboratories are required to immediately report results which indicate a patient is at critical risk, but there is little consensus about what values are deemed critical. The aim of this review was to systematically review the literature on alert thresholds for common chemistry and hematology tests in adults and to provide an explicit and ranked source of this evidence.
METHODS
The literature search covered the period of 1995–2014. Evidence sources were critically appraised and ranked using the 1999 Stockholm hierarchy for analytical performance specifications in laboratory medicine modified for establishing decision limits.
RESULTS
The 30 most frequently reported laboratory tests with alert thresholds are presented with evidence rankings. Similar thresholds were reported in North America, Europe and Asia. Seventy percent of papers reported thresholds set by individual institutions, while 18% contained thresholds from surveys of laboratories or clinicians. Forty-six percent of the papers referred to 1 or both of the 2 American laboratory surveys from the early 1990s. “Starter sets” of alert thresholds were recommended by 6 professional bodies, 3 of which were collaborations between pathologists and clinicians. None of the 9 outcome studies identified dealt with confounding factors.
CONCLUSIONS
Recommendations by professional bodies based on outdated surveys of the former state of the art or consensus are currently the best sources of evidence for laboratories to build their alert list. Well-designed outcome studies and greater collaboration between clinicians and the laboratory are needed to identify the most appropriate alert thresholds that signify actionable, critical or significant risk to patient well-being.
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Affiliation(s)
- Craig A Campbell
- The Centre for Health Systems and Safety Research (CHSSR), Australian Institute of Health Innovation, Macquarie University, NSW, Australia
- Department of Clinical Chemistry and Endocrinology, South Eastern Area Laboratory Services, NSW Health Pathology, NSW, Australia
| | - Andrew Georgiou
- The Centre for Health Systems and Safety Research (CHSSR), Australian Institute of Health Innovation, Macquarie University, NSW, Australia
| | - Johanna I Westbrook
- The Centre for Health Systems and Safety Research (CHSSR), Australian Institute of Health Innovation, Macquarie University, NSW, Australia
| | - Andrea R Horvath
- Department of Clinical Chemistry and Endocrinology, South Eastern Area Laboratory Services, NSW Health Pathology, NSW, Australia
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14
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Howanitz PJ, Darcy TP, Meier FA, Bashleben CP. Assessing Clinical Laboratory Quality: A College of American Pathologists Q-Probes Study of Prothrombin Time INR Structures, Processes, and Outcomes in 98 Laboratories. Arch Pathol Lab Med 2015; 139:1108-14. [DOI: 10.5858/arpa.2014-0464-cp] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Context
The anticoagulant warfarin has been identified as the second most frequent drug responsible for serious, disabling, and fatal adverse drug events in the United States, and its effect on blood coagulation is monitored by the laboratory test called international normalized ratio (INR).
Objective
To determine the presence of INR policies and procedures, INR practices, and completeness and timeliness of reporting critical INR results in participants' clinical laboratories.
Design
Participants reviewed their INR policies and procedure requirements, identified their practices by using a questionnaire, and studied completeness of documentation and timeliness of reporting critical value INR results for outpatients and emergency department patients.
Results
In 98 participating institutions, the 5 required policies and procedures were in place in 93% to 99% of clinical laboratories. Fifteen options for the allowable variations among duplicate results from different analyzers, 12 different timeliness goals for reporting critical values, and 18 unique critical value limits were used by participants. All required documentation elements were present in 94.8% of 192 reviewed INR validation reports. Critical value INR results were reported within the time frame established by the laboratory for 93.4% of 2604 results, but 1.0% of results were not reported. Although the median laboratories successfully communicated all critical results within their established time frames and had all the required validation elements based in their 2 most recent INR calculations, those participants at the lowest 10th percentile were successful in 80.0% and 85.7% of these requirements, respectively.
Conclusions
Significant opportunities exist for adherence to INR procedural requirements and for practice patterns and timeliness goals for INR critical results' reporting.
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Affiliation(s)
| | | | | | - Christine P. Bashleben
- From the Department of Pathology, State University of New York, Downstate Medical Center, Brooklyn (Dr Howanitz); the Department of Pathology, University of Wisconsin School of Medicine and Public Health, Madison, (Dr Darcy); the Department of Pathology, Henry Ford Health System, Detroit, Michigan (Dr Meier), and the Surveys Department, College of American Pathologists, Northfield, Illinois (Ms
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15
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Hallworth MJ, Epner PL, Ebert C, Fantz CR, Faye SA, Higgins TN, Kilpatrick ES, Li W, Rana SV, Vanstapel F. Current Evidence and Future Perspectives on the Effective Practice of Patient-Centered Laboratory Medicine. Clin Chem 2015; 61:589-99. [DOI: 10.1373/clinchem.2014.232629] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
AbstractBACKGROUNDSystematic evidence of the contribution made by laboratory medicine to patient outcomes and the overall process of healthcare is difficult to find. An understanding of the value of laboratory medicine, how it can be determined, and the various factors that influence it is vital to ensuring that the service is provided and used optimally.CONTENTThis review summarizes existing evidence supporting the impact of laboratory medicine in healthcare and indicates the gaps in our understanding. It also identifies deficiencies in current utilization, suggests potential solutions, and offers a vision of a future in which laboratory medicine is used optimally to support patient care.SUMMARYTo maximize the value of laboratory medicine, work is required in 5 areas: (a) improved utilization of existing and new tests; (b) definition of new roles for laboratory professionals that are focused on optimizing patient outcomes by adding value at all points of the diagnostic brain-to-brain cycle; (c) development of standardized protocols for prospective patient-centered studies of biomarker clinical effectiveness or extraanalytical process effectiveness; (d) benchmarking of existing and new tests in specified situations with commonly accepted measures of effectiveness; (e) agreed definition and validation of effectiveness measures and use of checklists for articles submitted for publication. Progress in these areas is essential if we are to demonstrate and enhance the value of laboratory medicine and prevent valuable information being lost in meaningless data. This requires effective collaboration with clinicians, and a determination to accept patient outcome and patient experience as the primary measure of laboratory effectiveness.
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Affiliation(s)
- Mike J Hallworth
- Department of Clinical Biochemistry, Royal Shrewsbury Hospital, Shrewsbury, Shropshire, UK
| | | | | | | | | | | | | | | | - S V Rana
- Department of Gastroenterology, PGIMER, Chandigarh, India
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16
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Campbell C, Horvath A. Harmonization of critical result management in laboratory medicine. Clin Chim Acta 2014; 432:135-47. [DOI: 10.1016/j.cca.2013.11.004] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2013] [Revised: 11/06/2013] [Accepted: 11/07/2013] [Indexed: 01/08/2023]
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17
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Tate JR, Johnson R, Barth J, Panteghini M. Harmonization of laboratory testing — Current achievements and future strategies. Clin Chim Acta 2014; 432:4-7. [DOI: 10.1016/j.cca.2013.08.021] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2013] [Accepted: 08/26/2013] [Indexed: 10/26/2022]
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18
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Yang D, Zhou Y, Yang C. Analysis of laboratory repeat critical values at a large tertiary teaching hospital in China. PLoS One 2013; 8:e59518. [PMID: 23516637 PMCID: PMC3597596 DOI: 10.1371/journal.pone.0059518] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2012] [Accepted: 02/15/2013] [Indexed: 11/22/2022] Open
Abstract
Context As a patient safety measure, laboratories are required to have a critical values policy by regulatory agencies. Unfortunately, little information is available on repeat critical values for the same analyte(s) on the same patient. Objective To investigate the occurrence and distribution of repeat critical values and the relationship between the frequency of such values and patient outcome to provide information for hospitals on improving reporting policies. Methods Eleven laboratory critical value lists, including chemistry and hematology analytes, were selected from a tertiary hospital in China in the year 2010. The distribution and interval time for each repeat critical value were calculated. Serum potassium and platelet count were used as examples to illustrate the relationship between the frequency of the repeat critical values and patient outcome. Results All test items on the critical value list were prone to the occurrence of repeat critical values. On average, each patient who experienced critical values had 2.10 occurrences. The median interval time for each repeat critical value varied, with most being longer than 8 hours. For those patients who had repeat critical values of serum potassium and platelet count, along with the increased frequency, the patients had a longer hospital stay and a generally worse outcome. Conclusions Patient can have a number of repeat critical values and the frequency of these values is closely related to patient outcome. A careful evaluation is warranted if a laboratory chooses to adopt a policy of not reporting each repeat critical value.
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Affiliation(s)
- Dagan Yang
- Department of Laboratory Medicine, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Yunxian Zhou
- School of Nursing, Zhejiang Chinese Medical University, Hangzhou, China
- * E-mail:
| | - Chunwei Yang
- Department of Laboratory Medicine, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
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19
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Abstract
Abstract
Clinical laboratories play an important role in improving patient care. The past decades have seen unbelievable, often unpredictable improvements in analytical performance. Although the seminal concept of the brain-to-brain laboratory loop has been described more than four decades ago, there is now a growing awareness about the importance of extra-analytical aspects in laboratory quality. According to this concept, all phases and activities of the testing cycle should be assessed, monitored and improved in order to decrease the total error rates thereby improving patients’ safety. Clinical Chemistry and Laboratory Medicine (CCLM) not only has followed the shift in perception of quality in the discipline, but has been the catalyst for promoting a large debate on this topic, underlining the value of papers dealing with errors in clinical laboratories and possible remedies, as well as new approaches to the definition of quality in pre-, intra-, and post-analytical steps. The celebration of the 50th anniversary of the CCLM journal offers the opportunity to recall and mention some milestones in the approach to quality and patient safety and to inform our readers, as well as laboratory professionals, clinicians and all the stakeholders of the willingness of the journal to maintain quality issues as central to its interest even in the future.
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Affiliation(s)
- Mario Plebani
- Department of Laboratory Medicine, University-Hospital of Padua, 35128 , Padua , Italy
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20
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Salinas M, López-Garrigós M, Asencio A, Lugo J, Gutiérrez M, Flors L, Leiva-Salinas C. Alert value reporting: a new strategy for patient safety. Clin Biochem 2012. [PMID: 23195137 DOI: 10.1016/j.clinbiochem.2012.11.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
OBJECTIVES The objectives of this study are to introduce the "alert value reporting" concept in primary care setting, to propose a list of chemistry and hematology alert limit tests that can be chosen for that strategy, to show how this notification procedure can be designed and established, and finally to evaluate the effectiveness and physicians' satisfaction regarding the proposed approach. In contrast to critical value reporting, alert value reporting would not allude to a result that may imply a life-threatening situation, but would indicate that an early diagnostic/therapeutic action would improve the patient's management and quality of life. DESIGN AND METHODS A list of chemistry and hematology alert limit tests to be used for the strategy was agreed upon between laboratory professionals and general practitioners. Next, a retrospective 12-month study involving more than 1 million laboratory tests was made to check how many of these alert values would have been communicated if these theoretical alert values had been applied. A prospective analysis of every reported alert value during 6 months was carried out to assess the intervention effectiveness and the requesting physician's satisfaction with the new strategy. RESULTS The alert value reporting was successfully executed. 20% of the reported alert values motivated the decision to reschedule the next patient's appointment. 90% of physicians considered alert value reporting as an interesting strategy to be continued. CONCLUSIONS Alert value reporting strategy motivated changes in patient's management. Further studies are needed to test if this approach can contribute to enhance patient safety and decision-making.
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Affiliation(s)
- Maria Salinas
- Clinical Laboratory Department, Hospital Universitario de San Juan, 03550-San Juan de Alicante, Spain.
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21
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Delanghe JR. Commentary. Clin Chem 2012; 58:1519. [PMID: 23104959 DOI: 10.1373/clinchem.2011.176321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Joris R Delanghe
- Department of Clinical Chemistry, Ghent University Hospital, Ghent, Belgium.
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22
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Loh TP, Saw S, Sethi SK. Critical Result Reporting: Don’t Miss the Forest for the Trees. Am J Clin Pathol 2012. [DOI: 10.1309/ajcp80zpxkealutg] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
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23
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The Point-of-Care Coordinator Training Program—Standardizing Point-of-Care Coordinator Training Globally. POINT OF CARE 2012. [DOI: 10.1097/poc.0b013e3182666e98] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Nakhleh RE, Myers JL, Allen TC, DeYoung BR, Fitzgibbons PL, Funkhouser WK, Mody DR, Lynn A, Fatheree LA, Smith AT, Lal A, Silverman JF. Consensus statement on effective communication of urgent diagnoses and significant, unexpected diagnoses in surgical pathology and cytopathology from the College of American Pathologists and Association of Directors of Anatomic and Surgical Pathology. Arch Pathol Lab Med 2012; 136:148-54. [PMID: 21992705 DOI: 10.5858/arpa.2011-0400-sa] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
CONTEXT Recognizing the difficulty in applying the concept of critical values to anatomic pathology diagnoses, the College of American Pathologists and the Association of Directors of Anatomic and Surgical Pathology have chosen to reevaluate the concept of critical diagnoses. OBJECTIVE To promote effective communication of urgent and significant, unexpected diagnoses in surgical pathology and cytology. DESIGN A comprehensive literature search was conducted and reviewed by an expert panel. RESULTS A policy of effective communication of important results in surgical pathology and cytology is desirable to enhance patient safety and to address multiple regulatory requirements. CONCLUSIONS Each institution should create its own policy regarding urgent diagnoses and significant, unexpected diagnoses in anatomic pathology. This policy should be separate from critical results or panic-value policies in clinical pathology, with the expectation of a different time frame for communication. Urgent diagnosis is defined as a medical condition that, in most cases, should be addressed as soon as possible. Significant, unexpected diagnosis is defined as a medical condition that is clinically unusual or unforeseen and should be addressed at some point in the patient's course. Further details of this statement are provided.
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Affiliation(s)
- Raouf E Nakhleh
- Department of Pathology, Mayo Clinic Florida, Jacksonville, 32224, USA.
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Plebani M, Saw S, Zaninotto M, Sciacovelli L, Piva E. Critical laboratory results: communication is just one of the problems. Am J Clin Pathol 2012; 137:164; author reply 165. [PMID: 22180492 DOI: 10.1309/ajcptcjqao1sv8ij] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022] Open
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Hawkins R. Managing the pre- and post-analytical phases of the total testing process. Ann Lab Med 2011; 32:5-16. [PMID: 22259773 PMCID: PMC3255486 DOI: 10.3343/alm.2012.32.1.5] [Citation(s) in RCA: 112] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2011] [Revised: 09/20/2011] [Accepted: 11/04/2011] [Indexed: 01/20/2023] Open
Abstract
For many years, the clinical laboratory's focus on analytical quality has resulted in an error rate of 4-5 sigma, which surpasses most other areas in healthcare. However, greater appreciation of the prevalence of errors in the pre- and post-analytical phases and their potential for patient harm has led to increasing requirements for laboratories to take greater responsibility for activities outside their immediate control. Accreditation bodies such as the Joint Commission International (JCI) and the College of American Pathologists (CAP) now require clear and effective procedures for patient/sample identification and communication of critical results. There are a variety of free on-line resources available to aid in managing the extra-analytical phase and the recent publication of quality indicators and proposed performance levels by the International Federation of Clinical Chemistry and Laboratory Medicine (IFCC) working group on laboratory errors and patient safety provides particularly useful benchmarking data. Managing the extra-laboratory phase of the total testing cycle is the next challenge for laboratory medicine. By building on its existing quality management expertise, quantitative scientific background and familiarity with information technology, the clinical laboratory is well suited to play a greater role in reducing errors and improving patient safety outside the confines of the laboratory.
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Affiliation(s)
- Robert Hawkins
- Department of Laboratory Medicine, Tan Tock Seng Hospital, Tan Tok Seng, Singapore.
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Abstract
Clinical laboratories have an important role in improving patient care. The past decades have seen enormous changes with unpredictable improvements in analytical performance, range of tests and capacity to manage large volumes of work. At the same time, there has been a dramatic fall in the rate of laboratory errors. However, there is now a growing awareness that the testing process includes the time before samples reach the laboratory and after reports have been printed and that these areas need to be included in the quality assessment of the total testing process. Laboratory quality should include a focus on patient safety and clinical effectiveness. Services should be patient-centred, timely, efficient and equitable, and finally, should be moulded to ensure optimal outcomes. There is a need to define quality indicators that will ensure there is appropriate choice and selection of tests, use of the appropriate assay standardization and the correct interpretation of the assay results at the appropriate time. These are the areas in which a quality laboratory can, and should, now involve itself.
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Affiliation(s)
- Julian H Barth
- Clinical Biochemistry, Leeds General Infirmary, Leeds LS1 3EX, UK.
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