Communicating critical test results: safe practice recommendations.

BACKGROUND: Massachusetts hospitals have collaborated in a patient safety initiative conducted by the Massachusetts Coalition for the Prevention of Medical Errors and the Massachusetts Hospital Association which is aimed at improving the ability to communicate critical test results in a timely and reliable way to the clinician who can take action. Solutions to this problem would address enhancing communication, teamwork, and information transfer, all fundamental system factors linked to patient safety. DEVELOPING THE SAFE PRACTICE RECOMMENDATIONS AND THE "STARTER SET": A Coalition-convened Consensus Group defined critical test results as values/interpretations for which reporting delays can result in serious adverse outcomes for patients. The scope included laboratory, cardiology, radiology, and other diagnostic tests in inpatient, emergency, and ambulatory settings. The Consensus Group developed Safe Practice Recommendations to promote successful communication of results, and a "starter set" of test results sufficiently abnormal to be widely agreed to be considered "critical." DISSEMINATION: The recommendations and the starter set of test results were disseminated in a statewide collaborative open to all Massachusetts hospitals. Hospitals' team members tested changes and shared successful strategies that improved the reliability of communicating critical test results. An evaluation of the results of this collaborative is underway.