An initiative to improve the management of clinically significant test results in a large health care network

nalyzing diagnostic errors in the acute setting: a process-driven approach

OBJECTIVES

We describe an approach for analyzing failures in diagnostic processes in a small, enriched cohort of general medicine patients who expired during hospitalization and experienced medical error. Our objective was to delineate a systematic strategy for identifying frequent and significant failures in the diagnostic process to inform strategies for preventing adverse events due to diagnostic error.

METHODS

Two clinicians independently reviewed detailed records of purposively sampled cases identified from established institutional case review forums and assessed the likelihood of diagnostic error using the Safer Dx instrument. Each reviewer used the modified Diagnostic Error Evaluation and Research (DEER) taxonomy, revised for acute care (41 possible failure points across six process dimensions), to characterize the frequency of failure points (FPs) and significant FPs in the diagnostic process.

RESULTS

Of 166 cases with medical error, 16 were sampled: 13 (81.3%) had one or more diagnostic error(s), and a total of 113 FPs and 30 significant FPs were identified. A majority of significant FPs (63.3%) occurred in "Diagnostic Information and Patient Follow-up" and "Patient and Provider Encounter and Initial Assessment" process dimensions. Fourteen (87.5%) cases had a significant FP in at least one of these dimensions.

CONCLUSIONS

Failures in the diagnostic process occurred across multiple dimensions in our purposively sampled cohort. A systematic analytic approach incorporating the modified DEER taxonomy, revised for acute care, offered critical insights into key failures in the diagnostic process that could serve as potential targets for preventative interventions.

Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses of Cancer

BACKGROUND

An ambulatory safety net (ASN) is an innovative organizational intervention for addressing patient safety related to missed and delayed diagnoses of abnormal test results. ASNs consist of a set of tools, reports and registries, and associated work flows to create a high-reliability system for abnormal test result management.

METHODS

Two ASNs implemented at an academic medical center are described, one focusing on colon cancer and the other on lung cancer. Data from electronic registries and chart reviews were used to evaluate the effectiveness of the ASNs, which were defined as follows: colon cancer-the proportion of patients who were scheduled for or completed a colonoscopy following safety net team outreach to the patient; lung cancer-the proportion of patients for whom the safety net was able to identify and implement appropriate follow-up, as defined by scheduled or completed chest CT.

RESULTS

The effectiveness of the colon cancer ASN was 44.0%, and the effectiveness of the lung cancer ASN was 56.9%. The ASNs led to the development of registries to address patient safety, fostered collaboration among interdisciplinary teams of clinicians and administrative staff, and created new work flows for patient outreach and tracking.

CONCLUSION

Two ASNs were successfully implemented at an academic medical center to address missed and delayed recognition of abnormal test results related to colon cancer and lung cancer. The ASNs are providing a framework for development of additional safety nets in the organization.

Decision Support Tools within the Electronic Health Record

Laboratory tests are an integral part of the electronic health record (EHR). Providing clinical decision support (CDS) for the ordering, collection, reporting, viewing, and interpretation of laboratory testing is a fundamental function of the EHR. The implementation of a sustainable, effective laboratory CDS program requires a commitment to standardization and harmonization of the laboratory dictionaries that are the foundation of laboratory-based CDS. In this review, the authors provide an overview of the tools available within the EHR to improve decision making throughout the entire laboratory testing process, from test order to clinical action.

The Impact of Automated Notification on Follow-up of Actionable Tests Pending at Discharge: a Cluster-Randomized Controlled Trial

BACKGROUND

Follow-up of tests pending at discharge (TPADs) is poor. We previously demonstrated a twofold increase in awareness of any TPAD by attendings and primary care physicians (PCPs) using an automated email intervention OBJECTIVE: To determine whether automated notification improves documented follow-up for actionable TPADs DESIGN: Cluster-randomized controlled trial SUBJECTS: Attendings and PCPs caring for adult patients discharged from general medicine and cardiology services with at least one actionable TPAD between June 2011 and May 2012 INTERVENTION: An automated system that notifies discharging attendings and network PCPs of finalized TPADs by email MAIN MEASURES: The primary outcome was the proportion of actionable TPADs with documented action determined by independent physician review of the electronic health record (EHR). Secondary outcomes included documented acknowledgment, 30-day readmissions, and adjusted median days to documented follow-up.

KEY RESULTS

Of the 3378 TPADs sampled, 253 (7.5%) were determined to be actionable by physician review. Of these, 150 (123 patients discharged by 53 attendings) and 103 (90 patients discharged by 44 attendings) were assigned to intervention and usual care groups, respectively, and underwent chart review. The proportion of actionable TPADs with documented action was 60.7 vs. 56.3% (p = 0.82) in the intervention vs. usual care groups, similar for documented acknowledgment. The proportion of patients with actionable TPADs readmitted within 30 days was 22.8 vs. 31.1% in the intervention vs. usual care groups (p = 0.24). The adjusted median days [95% CI] to documented action was 9 [6.2, 11.8] vs. 14 [10.2, 17.8] (p = 0.04) in the intervention vs. usual care groups, similar for documented acknowledgment. In sub-group analysis, the intervention had greater impact on documented action for patients with network PCPs compared with usual care (70 vs. 50%, p = 0.03).

CONCLUSIONS

Automated notification of actionable TPADs shortened time to action but did not significantly improve documented follow-up, except for network-affiliated patients. The high proportion of actionable TPADs without any documented follow-up (~ 40%) represents an ongoing safety concern.

CLINICAL TRIALS IDENTIFIER

NCT01153451.

Semiautomated System for Nonurgent, Clinically Significant Pathology Results

BACKGROUND

Failure of timely test result follow-up has consequences including delayed diagnosis and treatment, added costs, and potential patient harm. Closed-loop communication is key to ensure clinically significant test results (CSTRs) are acknowledged and acted upon appropriately. A previous implementation of the Alert Notification of Critical Results (ANCR) system to facilitate closed-loop communication of imaging CSTRs yielded improved communication of critical radiology results and enhanced adherence to institutional CSTR policies.

OBJECTIVE

This article extends the ANCR application to pathology and evaluates its impact on closed-loop communication of new malignancies, a common and important type of pathology CSTR.

MATERIALS AND METHODS

This Institutional Review Board-approved study was performed at a 150-bed community, academically affiliated hospital. ANCR was adapted for pathology CSTRs. Natural language processing was used on 30,774 pathology reports 13 months pre- and 13 months postintervention, identifying 5,595 reports with malignancies. Electronic health records were reviewed for documented acknowledgment for a random sample of reports. Percent of reports with documented acknowledgment within 15 days assessed institutional policy adherence. Time to acknowledgment was compared pre- versus postintervention and postintervention with and without ANCR alerts. Pathologists were surveyed regarding ANCR use and satisfaction.

RESULTS

Acknowledgment within 15 days was documented for 98 of 107 (91.6%) pre- and 89 of 103 (86.4%) postintervention reports (p = 0.2294). Median time to acknowledgment was 7 days (interquartile range [IQR], 3, 11) preintervention and 6 days (IQR, 2, 10) postintervention (p = 0.5083). Postintervention, median time to acknowledgment was 2 days (IQR, 1, 6) for reports with ANCR alerts versus 6 days (IQR, 2.75, 9) for reports without alerts (p = 0.0351). ANCR alerts were sent on 15 of 103 (15%) postintervention reports. All pathologists reported that the ANCR system positively impacted their workflow; 75% (three-fourths) felt that the ANCR system improved efficiency of communicating CSTRs.

CONCLUSION

ANCR expansion to facilitate closed-loop communication of pathology CSTRs was favorably perceived and associated with significant improved time to documented acknowledgment for new malignancies. The rate of adherence to institutional policy did not improve.

'Who's Covering This Patient?' Developing a First-Contact Provider (FCP) Designation in an Electronic Health Record

BACKGROUND

Safe and efficient inpatient care depends on accurate identification of the licensed independent practitioner (LIP) primarily responsible for each admitted patient. The inability to do so has far-reaching consequences, including poor communication among care teams, delays in patient care (including critical result reporting), and significant threats to patient safety.

METHODS

At the University of Chicago Medical Center, an 800-bed academic hospital, a new Epic feature, called First-Contact Provider (FCP), was developed to identify the responsible LIP for each inpatient. The number of patients with only one designated FCP at a given time was audited daily. To ensure correct technical function, the number of Best Practice Advisories (BPAs) alerting of no documented FCP was measured. The number of inpatient critical lab values reported directly to LIPs was measured as a proxy for the accuracy of FCP in identifying the correct LIP.

RESULTS

During the nine-month study period, the average daily inpatient census was 568 and the average monthly critical lab volume was 1,727. By the end of the study, the weekly mean percentage of patients with one FCP documented at noon reached 98.6%. The weekly mean number of BPAs dropped from 5,313/day to less than 50/day. The monthly mean percentage of critical results reported directly to LIPs increased from a pre-FCP baseline of 18.0% to 87.8%.

CONCLUSION

FCP largely solved the far-reaching problem of accurate LIP identification for hospitalized patients. This, in turn, significantly improved the ability to report inpatient critical lab values directly to LIPs.

Critical Value Reporting in Transfusion Medicine: A Survey of Communication Practices in US Facilities

OBJECTIVES

While critical value procedures have been adopted in most areas of the clinical laboratory, their use in transfusion medicine has not been reviewed in detail. The results of this study present a comprehensive overview of critical value reporting and communication practices in transfusion medicine in the United States.

METHODS

A web-based survey was developed to collect data on the prevalence of critical value procedures and practices of communicating results. The survey was distributed via email to US hospital-based blood banks.

RESULTS

Of 123 facilities surveyed, 84 (68.3%) blood banks had a critical value procedure. From a panel of 23 common blood bank results, nine results were selected by more than 70% of facilities as either a critical value or requiring rapid communication as defined by an alternate procedure.

CONCLUSIONS

There was overlap among results communicated by facilities with and without a critical value procedure. The most frequently communicated results, such as incompatible crossmatch for RBC units issued uncrossmatched, delay in finding compatible blood due to a clinically significant antibody, and transfusion reaction evaluation suggestive of a serious adverse event, addressed scenarios associated with the leading reported causes of transfusion-related fatalities.

Using health-system-wide data to understand hepatitis B virus prophylaxis and reactivation outcomes in patients receiving rituximab

Hepatitis B virus (HBV) reactivation in the setting of rituximab use is a potentially fatal but preventable safety event. The rate of HBV screening and proportion of patients at risk who receive antiviral prophylaxis in patients initiating rituximab is unknown.We analyzed electronic health record (EHR) data from 2 health systems, a university center and a safety net health system, including diagnosis grouper codes, problem lists, medications, laboratory results, procedures codes, clinical encounter notes, and scanned documents. We identified all patients who received rituximab between 6/1/2012 and 1/1/2016. We calculated the proportion of rituximab users with inadequate screening for HBV according to the Centers for Disease Control guidelines for detecting latent HBV infection before their first rituximab infusion during the study period. We also assessed the proportion of patients with positive hepatitis B screening tests who were prescribed antiviral prophylaxis. Finally, we characterized safety failures and adverse events.We included 926 patients from the university and 132 patients from the safety net health system. Sixty-one percent of patients from the university had adequate screening for HBV compared with 90% from the safety net. Among patients at risk for reactivation based on results of HBV testing, 66% and 92% received antiviral prophylaxis at the university and safety net, respectively.We found wide variations in hepatitis B screening practices among patients receiving rituximab, resulting in unnecessary risks to patients. Interventions should be developed to improve patient safety procedures in this high-risk patient population.

Critical Findings: Attempts at Reducing Notification Errors

PURPOSE

Ineffective communication of critical findings (CFs) is a patient safety issue. The aim of this study was to assess whether a feedback program for faculty members failing to correctly report CFs would lead to improved compliance.

METHODS

Fifty randomly selected reports were reviewed by the chief of neuroradiology each month for 42 months. Errors included (1) not calling for a CF, (2) not identifying a CF as such, (3) mischaracterizing non-CFs as CFs, and (4) calling for non-CFs. The number of appropriately handled and mishandled reports in each month was recorded. The trend of error reduction after the division chief provided feedback in the subsequent months was evaluated, and the equality of time interval between errors was tested.

RESULTS

Among 2,100 reports, 49 (2.3%) were handled inappropriately. Among non-CF reports, 98.97% (1,817 of 1,836) were appropriately not called and not flagged, and 88.64% (234 of 264) of CF reports were called and flagged appropriately. The error rate during the 11th through 32nd months of review (1.28%) was significantly lower than the error rate in the first 10 months of review (3.98%) (P = .001). This benefit lasted for 21 months.

CONCLUSIONS

Review and giving feedback to radiologists increased their compliance with the CF protocol and decreased deviations from standard operating procedures for about 2 years (from month 10 to month 32). Developing new ideas for improving CF policy compliance may be required at 2- to 3-year intervals to provide continuous quality improvement.

Impact of an electronic alert notification system embedded in radiologists' workflow on closed-loop communication of critical results: a time series analysis

INTRODUCTION

Optimal critical test result communication is a Joint Commission national patient safety goal and requires documentation of closed-loop communication among care providers in the medical record. Electronic alert notification systems can facilitate an auditable process for creating alerts for transmission and acknowledgement of critical test results. We evaluated the impact of a patient safety initiative with an alert notification system on reducing critical results lacking documented communication, and assessed potential overuse of the alerting system for communicating results.

METHODS

We implemented an alert notification system-Alert Notification of Critical Results (ANCR)-in January 2010. We reviewed radiology reports finalised in 2009-2014 which lacked documented communication between the radiologist and another care provider, and assessed the impact of ANCR on the proportion of such reports with critical findings, using trend analysis over 10 semiannual time periods. To evaluate potential overuse of ANCR, we assessed the proportion of reports with non-critical results among provider-communicated reports.

RESULTS

The proportion of reports with critical results among reports without documented communication decreased significantly over 4 years (2009-2014) from 0.19 to 0.05 (p<0.0001, Cochran-Armitage trend test). The proportion of provider-communicated reports with non-critical results remained unchanged over time before and after ANCR implementation (0.20 to 0.15, p=0.45, Cochran-Armitage trend test).

CONCLUSIONS

A patient safety initiative with an alert notification system reduced the proportion of critical results among reports lacking documented communication between care providers. We observed no change in documented communication of non-critical results, suggesting the system did not promote overuse. Future studies are needed to evaluate whether such systems prevent subsequent patient harm.

Does integrating nonurgent, clinically significant radiology alerts within the electronic health record impact closed-loop communication and follow-up?

OBJECTIVE

To assess whether integrating critical result management software--Alert Notification of Critical Results (ANCR)--with an electronic health record (EHR)-based results management application impacts closed-loop communication and follow-up of nonurgent, clinically significant radiology results by primary care providers (PCPs).

MATERIALS AND METHODS

This institutional review board-approved study was conducted at a large academic medical center. Postintervention, PCPs could acknowledge nonurgent, clinically significant ANCR-generated alerts ("alerts") within ANCR or the EHR. Primary outcome was the proportion of alerts acknowledged via EHR over a 24-month postintervention. Chart abstractions for a random sample of alerts 12 months preintervention and 24 months postintervention were reviewed, and the follow-up rate of actionable alerts (eg, performing follow-up imaging, administering antibiotics) was estimated. Pre- and postintervention rates were compared using the Fisher exact test. Postintervention follow-up rate was compared for EHR-acknowledged alerts vs ANCR.

RESULTS

Five thousand nine hundred and thirty-one alerts were acknowledged by 171 PCPs, with 100% acknowledgement (consistent with expected ANCR functionality). PCPs acknowledged 16% (688 of 4428) of postintervention alerts in the EHR, with the remaining in ANCR. Follow-up was documented for 85 of 90 (94%; 95% CI, 88%-98%) preintervention and 79 of 84 (94%; 95% CI, 87%-97%) postintervention alerts (P > .99). Postintervention, 11 of 14 (79%; 95% CI, 52%-92%) alerts were acknowledged via EHR and 68 of 70 (97%; 95% CI, 90%-99%) in ANCR had follow-up (P = .03).

CONCLUSIONS

Integrating ANCR and EHR provides an additional workflow for acknowledging nonurgent, clinically significant results without significant change in rates of closed-loop communication or follow-up of alerts.

Linking acknowledgement to action: closing the loop on non-urgent, clinically significant test results in the electronic health record

Failure to follow-up nonurgent, clinically significant test results (CSTRs) is an ambulatory patient safety concern. Tools within electronic health records (EHRs) may facilitate test result acknowledgment, but their utility with regard to nonurgent CSTRs is unclear. We measured use of an acknowledgment tool by 146 primary care physicians (PCPs) at 13 network-affiliated practices that use the same EHR. We then surveyed PCPs to assess use of, satisfaction with, and desired enhancements to the acknowledgment tool. The rate of acknowledgment of non-urgent CSTRs by PCPs was 78%. Of 73 survey respondents, 72 reported taking one or more actions after reviewing a CSTR; fewer (40-75%) reported that using the acknowledgment tool was helpful for a specific purpose. Forty-six (64%) were satisfied with the tool. Both satisfied and nonsatisfied PCPs reported that enhancements linking acknowledgment to routine actions would be useful. EHR vendors should consider enhancements to acknowledgment functionality to ensure follow-up of nonurgent CSTRs.

Emergency physicians' views of direct notification of laboratory and radiology results to patients using the Internet: a multisite survey

BACKGROUND

Patients are increasingly using the Internet to communicate with health care providers and access general and personal health information. Missed test results have been identified as a critical safety issue with studies showing up to 75% of tests for emergency department (ED) patients not being followed-up. One strategy that could reduce the likelihood of important results being missed is for ED patients to have direct access to their test results. This could be achieved electronically using a patient portal tied to the hospital's electronic medical record or accessed from the relevant laboratory information system. Patients have expressed interest in accessing test results directly, but there have been no reported studies on emergency physicians' opinions.

OBJECTIVE

The aim was to explore emergency physicians' current practices of test result notification and attitudes to direct patient notification of clinically significant abnormal and normal test results.

METHODS

A cross-sectional survey was self-administered by senior emergency physicians (site A: n=50; site B: n=39) at 2 large public metropolitan teaching hospitals in Australia. Outcome measures included current practices for notification of results (timing, methods, and responsibilities) and concerns with direct notification.

RESULTS

The response rate was 69% (61/89). More than half of the emergency physicians (54%, 33/61) were uncomfortable with patients receiving direct notification of abnormal test results. A similar proportion (57%, 35/61) was comfortable with direct notification of normal test results. Physicians were more likely to agree with direct notification of normal test results if they believed it would reduce their workload (OR 5.72, 95% CI 1.14-39.76). Main concerns were that patients could be anxious (85%, 52/61), confused (92%, 56/61), and lacking in the necessary expertise to interpret their results (90%, 55/61).

CONCLUSIONS

Although patients' direct access to test results could serve as a safety net reducing the likelihood of abnormal results being missed, emergency physicians' concerns need further exploration: which results are suitable and the timing and method of direct release to patients. Methods of access, including secure Web-based patient portals with drill-down facilities providing test descriptions and result interpretations, or laboratories sending results directly to patients, need evaluation to ensure patient safety is not compromised and the processes fit with ED clinician and laboratory work practices and patient needs.

Four-year impact of an alert notification system on closed-loop communication of critical test results

OBJECTIVE

One of the patient safety goals proposed by the Joint Commission urges hospitals to develop a policy for communicating critical test results and to measure adherence to that policy. We evaluated the impact of an alert notification system on policy adherence for communicating critical imaging test results to referring providers and assessed system adoption over the first 4 years after implementation.

MATERIALS AND METHODS

This study was performed in a 753-bed academic medical center. The intervention, an automated alert notification system for critical results, was implemented in January 2010. The primary outcome was adherence to institutional policy for timely closed-loop communication of critical imaging results, and the secondary outcome was system adoption. Policy adherence was determined through manual review of a random sample of radiology reports from the first 4 years after the intervention (n = 37,604) compared with baseline outcomes 1 year before the intervention (n = 9430). Adoption was evaluated by quantifying the use of the system overall and the proportion of alerts that used noninterruptive communication as a percentage of all reports generated by 320 radiologists (n = 1,538,059). A statistical analysis of the trend at 6-month intervals over 4 years was performed using a chi-square trend test.

RESULTS

Adherence to the policy increased from 91.3% before the intervention to 95.0% after the intervention (p < 0.0001). There was a ninefold increase in the critical results communicated via the system (chi-square trend test, p < 0.0001). During the first 4 years after the intervention, 41,445 alerts (41% of the total number of alerts) used the system's noninterruptive process for communicating less urgent critical results, which was substantially unchanged over the 4 years postintervention, thus reducing unnecessary paging interruptions.

CONCLUSION

An automated alert notification system for communicating critical imaging results was successfully adopted and was associated with increased adherence to institutional policy for communicating critical test results and with reduced workflow interruptions.

How context affects electronic health record-based test result follow-up: a mixed-methods evaluation

OBJECTIVES

Electronic health record (EHR)-based alerts can facilitate transmission of test results to healthcare providers, helping ensure timely and appropriate follow-up. However, failure to follow-up on abnormal test results (missed test results) persists in EHR-enabled healthcare settings. We aimed to identify contextual factors associated with facility-level variation in missed test results within the Veterans Affairs (VA) health system.

DESIGN, SETTING AND PARTICIPANTS

Based on a previous survey, we categorised VA facilities according to primary care providers' (PCPs') perceptions of low (n=20) versus high (n=20) risk of missed test results. We interviewed facility representatives to collect data on several contextual factors derived from a sociotechnical conceptual model of safe and effective EHR use. We compared these factors between facilities categorised as low and high perceived risk, adjusting for structural characteristics.

RESULTS

Facilities with low perceived risk were significantly more likely to use specific strategies to prevent alerts from being lost to follow-up (p=0.0114). Qualitative analysis identified three high-risk scenarios for missed test results: alerts on tests ordered by trainees, alerts 'handed off' to another covering clinician (surrogate clinician), and alerts on patients not assigned in the EHR to a PCP. Test result management policies and procedures to address these high-risk situations varied considerably across facilities.

CONCLUSIONS

Our study identified several scenarios that pose a higher risk for missed test results in EHR-based healthcare systems. In addition to implementing provider-level strategies to prevent missed test results, healthcare organisations should consider implementing monitoring systems to track missed test results.

Electronic Clinical Surveillance to Improve Outpatient Care: Diverse Applications within an Integrated Delivery System

Efforts to improve patient safety have largely focused on inpatient or emergency settings, but the importance of patient safety in ambulatory care is increasingly being recognized as a key component of overall health care quality. Care gaps in outpatient settings may include missed diagnoses, medication errors, or insufficient monitoring of patients with chronic conditions or on certain medications. Further, care gaps may occur across a wide range of clinical conditions. We report here an innovative approach to improve patient safety in ambulatory settings – the Kaiser Permanente Southern California (KPSC) Outpatient Safety Net Program – which leverages electronic health information to efficiently identify and address a variety of potential care gaps across different clinical conditions.

Between 2006 and 2012, the KPSC Outpatient Safety Net Program implemented 24 distinct electronic clinical surveillance programs, which routinely scan the electronic health record to identify patients with a particular condition or event. For example, electronic clinical surveillance may be used to scan for harmful medication interactions or potentially missed diagnoses (e.g., abnormal test results without evidence of subsequent care). Keys to the success of the program include strong leadership support, a proactive clinical culture, the blame-free nature of the program, and the availability of electronic health information. The Outpatient Safety Net Program framework may be adopted by other organizations, including those who have electronic health information but not an electronic health record. In the future, the creation of a forum to share electronic clinical surveillance programs across organizations may facilitate more rapid improvements in outpatient safety.