The Problem
"In our database of over 3,000 sentinel events (deaths and major disability resulting from care) and their root cause analyses, the most frequently cited causative factor – over two-thirds of the cases – is ineffective communication."
– Dr. Richard Croteau, executive director for patient safety initiatives at the Joint Commission on Accreditation of Healthcare Organizations
Dallas Morning News, Sept. 13, 2005
Failures and delays in the communication of critical test results is the Achilles' Heel of health care delivery.
The Joint Commission on Accreditation of Healthcare Organizations and the National Institute of Medicine have identified these types of communication problems as a threat to patient safety. JCAHO's National Patient Safety Goals specifically address the issue.
Radiology receives much of the attention as a source of the problem, but, in fact, every diagnostic department faces potential liability from this issue.
The Clinical Laboratory Improvement Amendments of 1988 also specifically address the problem. CLIA Sec. 493.1234 Standard: Communications states, for example:
"The laboratory must have a system in place to identify and document problems that occur as a result of a breakdown in communication between the laboratory and an authorized individual who orders or receives test results."
Even where hospitals genuinely believe they have addressed the problem, the reality often is very different.
The typical "systems" for delivering and managing critical test results are mostly manual, disjointed, inefficient, prone to error, and frustratingly inconsistent across hospitals within a system and across diagnostic departments within a hospital.
Threats to patient safety, such as error-prone and inefficient manual "systems" for communicating critical test results, adversely affect patient outcomes.
Similarly, manual systems waste valuable staff time and drag down productivity – threatening the health of the institution.
Fortunately, thanks to advances in technology, it does not have to be this way.