Ineffective communication of critical and significant test results is a systematic problem that is the most frequently cited category of root cause sentinel events in a healthcare environment. The ability for healthcare management systems to timely flag, report, accurate, complete and unambiguous results ultimately is known as Critical Tests Results Management or CTRM. 

Research and Findings of Regulatory Bodies

It is of such importance that The Joint Commission has made “effective communications among health caregivers” its #2 National Patient Safety Goal again in 2010 for the seventh straight year.

The American College of Radiology’s (ACR) 2003 guidelines included “communication is a critical component of the art and science of medicine and is especially important in diagnostic radiology.”

The Clinical Laboratory Improvement Amendments of 1988 (CLIA) standards for communications state that “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.”

Existing Processes are Prone to Mistakes

While every hospital and healthcare institution has some system of communicating critical and significant test values in place, most have not taken advantage of modern information technology to both communicate and document these successful and effective communications and measure its performance against its stated goals. To exacerbate the problem, almost all of the attention to this problem area has been focused on critical test results, overlooking the non-emergent but equally important significant, unexpected findings that, if go unnoticed through lack of effective communication, can result in equally poor patient outcomes over time.

As a result patient safety and outcomes are not being maximized while staff productivity suffers utilizing inefficient communication systems.