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Reporting Critical Test Results: A National Patient Safety Goal

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Reporting Critical Test Results: A National Patient Safety Goal

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Reporting Critical Test Results

When we think of reporting critical test results, we usually think of results obtained through blood or radiological testing. The Joint Commission requires staff to report critical test results; this is a National Patient Safety Goal. But critical test results go beyond this concept. Consider this case.

A Connecticut woman’s fetus died. The obstetrician induced labor and instructed the nurse on duty to allow the placenta to deliver on its own. The nurse sent all of the products of conception to the pathology lab, where the pathologist concluded that what the nurse had thought was the placenta was only a blood clot. The placenta had not been delivered. He called the Labor and Delivery Unit to notify them of his findings, and made two attempts to call the obstetrician, who did not return his calls. He then faxed a copy of the report to the doctor’s office. The obstetrician never got any of these messages. A few days after discharge from the hospital, the patient called her obstetrician to report she had vaginal bleeding and a fever. He testified he advised her to go to the hospital, but she could not do so due to child care issues. She testified that he did not tell her to go to the hospital, rather he merely prescribed antibiotics and told her to come to his office in the morning. The next day he discovered the placenta and attempted to remove it, perforated her uterus, and had to do an emergency removal of her uterus to save her life. The jury found the obstetrician negligent and the court of appeals agreed.

Analysis of the Retained Placenta Case
In this case, there was a breakdown in communication that harmed the patient. Should the pathologist have stopped trying before he spoke to the obstetrician? Should the nurses have made sure the obstetrician knew of the problem? All areas of the hospital staff need to define critical findings and have a mechanism to ensure that they are transmitted to the ordering provider. While the obstetrician took the blame in this case, others in the chain of events had a part in the communication process. There is a constant need for good communication.

Recommendations for Critical Test Results Cases
Attorneys litigating cases involving reporting critical test results need to find out:

  • The facility’s procedures and policies regarding reporting critical test results
  • Which tests/results are considered critical
  • What is the expectation of the timeframe for reporting critical test results – immediately upon receipt of results, within an hour, longer?
  • The course of action a provider should follow if the responsible provider cannot be reached
  • The chain of command to be used if a provider does not appropriately respond to a report of a critical test result
  • What the medical record says transpired – who called who, when and what was said, what occurred after that?
  • What deponents say happened, which may or may not match what the medical record says

Contact us for help in locating well-qualified expert witnesses to review your cases.

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