Monday, November 28, 2011

Dangerous Assumptions & Lack of Systems: Breakdown in Communication of Test Results

This article in the Washington Post points out a disturbing, yet unfortunately widespread, cause of medical errors: breakdown in communication of test results.

The Joint Commission addresses the issue as one of its National Patient Safety Goals for hospitals. However, systems at many hospitals and physician offices are not "airtight" enough to assure the reliable transmission of information and the delivery of safe care.

The "root cause" for this error generally comes down to one of a few common factors:
  • Staff too busy with their "day-to-day" routine. 
    • If the result reporting process is not well-integrated into their clinical workflow, there is a high likelihood of system failure.
  • No clear process identified for handling of critical lab results.
    • This is probably the "over-arching" root cause for the issue at hand. If the process for communication is not robust, not well disseminated, and not monitored, it will inevitably lead to errors. 
  • Miscommunication about who in the hospital/ office is handling the communication.
    • Results may get reported to a non-clinical staff member (such as a Unit Clerk or Office Manager) who is not the right individual to interpret the significance of the findings.
  • Physician was not reachable despite numerous attempts.
    • Sorry to say that this is probably one of the most common reasons for failure to relay critical test information, particularly in a busy hospital setting. 
    • Lab techs, nurses, and other staff try to follow an "established process", but the process is doomed to repetitive failure because one of the key steps is not reliable.
  • Results get communicated, but subsequent "changes to reports" are lost. 
    • Unfortunately, this happens often for tests that have to be "incubated" (such as microbiology reports) or "reviewed" (such as radiology reports).
  • Test results that cross clinical settings (such as hospital to provider office) are prone to getting lost. 
    • Every provider and every hospital may have a different mechanism and process for communicating critical test results. This increases the complexity of the process exponentially, and makes it more prone to break down.
    • When there is not "one standardized process for communication" across the local healthcare system, how do we expect individual physicians, staff, and even organizations to ensure reliability?
The system described by Dr. Eric Poon at Brigham and Womens Hospital is a constructive approach to this problem:

However, this system is mostly reliant on an electronic interface, which may not be applicable to all providers in a diversity of clinical settings. In addition to using electronic systems wisely, healthcare providers should remember the key principles of performance improvement for systematically reducing the likelihood of error in this vital clinical process:
  • Undertake a root cause analysis for any specific errors at the respective institution
  • Undertake a FMEA (failure modes effect analysis) to formally assess the likelihood of systems breakdown for key processes
  • Ensure that a specific process is laid out and communicated widely to all staff and physicians
  • Build in redundancies to ensure that an "adequate safety net" is in place to catch errors before they affect a patient
  • Monitor data both on outcomes (errors reaching the patient) as well as critical steps in the process (such as success in test result handoffs)
  • Report data widely to staff, physicians, leadership
  • Provide feedback to staff and physicians on individual errors
  • Incorporate education about process into staff orientation and ongoing training forums

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