Fail-safe: Automating Critical-results Notification

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The radiology department at Brigham and Women’s Hospital (BWH), Boston, Massachusetts, developed a policy for communicating critical and discrepant results after the Joint Commission made communications among caregivers a national priority for health-care providers. When the goal was expanded in 2007, the department took the next step and used IT to automate the process and to embed it into radiologist and referring-physician workflow.

Brigham HospitalNonetheless, the journey begins with a policy based on strict definitions of critical and discrepant findings, according to Luciano Prevedello, MD, a neuroradiology and informatics fellow in BWH’s radiology department. He described the solution in “Methods for Effective Communication and Reporting,” presented on June 4, 2010, at the annual Society for Imaging Informatics in Medicine meeting in Minneapolis, Minnesota. Noting that it is common, in the reading room, to hear radiologists question whether a particular result is critical, he says, “If you don’t have strict definitions of what a critical or discrepant finding is, then it is going to be a problem for people to use the policy and be compliant.”

BWH must have gotten it right. Since February 2006, the department’s compliance has moved from 30% to almost 95% in 2010. This is how they did it.

Setting a Policy

In 2004, the Joint Commission released a list of National Patient Safety Goals to be used in accrediting health-care providers, and goal number 2 was of particular relevance to radiology: Improve effectiveness of communication among caregivers. With each passing year, the Joint Commission added further requirements to this goal, until by 2007, it included four specifications for hospitals:

• for verbal or phone orders, as well as for reporting critical test results by phone, verify the complete order (or the test results) by having the person who receives the order or result record the information and read it to the speaker/caller;
• create a standardized list, applicable throughout the organization, of abbreviations, acronyms, symbols, and dose designations that are not to be used;
• measure and assess timelines for the reporting of all critical test results and for the receipt of those results by the responsible licensed caregiver; as needed, take action to improve those timelines; and
• implement a standardized approach to handing off messages or other communications, including in that approach a chance for both parties to ask and respond to questions.

BWH began by creating a policy for all critical and discrepant results that included mandating use of the language found in the templateapproved by the Structured Reporting Subcommittee of the RSNA in all reports that have critical or discrepant results.

“In our system, a critical result is defined as a new or unexpected finding that could result in mortality or significant morbidity if appropriate diagnostic or therapeutic follow-up steps are not undertaken,” Prevedello explains. “Discrepant findings are defined as an interpretation that is significantly different from a preliminary interpretation, when the preliminary interpretation has been accessible to the patient-care team and the difference in the interpretation may alter the patient’s diagnostic work-up or management.”

Stratifying Critical Results

Critical alerts were divided into three categories (with appropriate responses).

Red: findings that are potentially immediately life threatening; these require immediate interruptive communication, such as face-to-face communication or phone contact.

Orange: findings that could result in mortality or significant morbidity if not appropriately treated urgently; these require face-to-face communication and phone contact.

Yellow: findings that could result in mortality or significant morbidity if not appropriately treated, but that are not immediately life threatening or urgent; face-to-face contact, phone contact, or other verifiable methods of communication are required. Some hospitals do not include these results as critical, but BWH chose to set the bar high.

The time frames for notifying the appropriate personnel (and documenting that notification) were established as less than 60 minutes for red alerts, within three hours for orange alerts, and within three days for yellow alerts.

In compliance with the recommendation of the RSNA subcommittee, the policy requires documentation to be included in the radiology report. It must contain the following