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PRINCIPLE/PURPOSE:
Ministry Saint Michael’s Hospital and Ministry Medical Group-Central Region will
communicate the results of tests considered critical to patient care to the responsible
licensed caregiver in a timely and reliable manner according to established guidelines.
1.0 To prevent delays in taking actions in responding to critical tests and critical
results that may have the potential for serious harm to the patient.
2.0 To define critical tests and critical results.
3.0 To establish a communication processes with the responsible licensed caregiver
4.0 To develop a system for measuring and assessing the timeliness of reporting
critical tests and critical results with the goal of ensuring timely reporting.
DEFINITIONS:
Critical Test Result: Those test results that fall significantly outside the normal range
and/or may represent life-threatening values, even from routine tests and that require
rapid communication of results to the responsible caregiver. A delay in taking action to
respond to the result may result in a serious adverse outcome for the patient. In addition,
panic/alert/critical results as defined by reference laboratories will be used for tests
completed outside the organization. Critical test results are defined by the performing
department in collaboration with Ministry Saint Michael’s Hospital and Ministry Medical
Group-Central Region medical staff.
In the event that a patient’s provider cannot be reached and does not respond to a
call/page, the call will be repeated in 15 minutes. If successful contact cannot be
established, the on-call physician will be paged. If no response, follow the chain of
command.
Results from critical tests and critical results must be called after verification in the
laboratory. Results are called to authorized staff or the responsible licensed caregiver.
Results on patients designated as “temp location” or Operating Room will be sent directly
to the O.R. printer. Additionally, call the O.R. to notify that it’s printed.
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Critical Tests
• OR frozen section
• See attached chart for specific critical lab values
Special circumstances
Tests may be done in departments (e.g. ICU or WIC) where provisions have been made
by the physician provider for the clinical management of critical results, such as a signed
order set for electrolyte replacement or glucose management via insulin drop titration.
These tests may have critical results, but the nurse, following the appropriate parameters
as set forth in the respective orders set, will respond on behalf of the provider.
1.0 Calling of Critical Laboratory Values and critical tests to caregivers or designees
Critical Values and other laboratory results called to health care staff or designees
must be documented in the MEDITECH system and be done within time frames
established.
The following is the format that should be used for calling /documenting all
results:
Use canned text "LCALL" to document that you called a critical value listed on
the attached Critical Value List to someone other than a provider:
Use canned text "LCALLMD" to document that you called a critical value listed
on the attached Critical Value List directly to the provider:
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Results read-back by provider.
Use canned text “CALL” to document that you called a result to a licensed
caregiver that is not deemed as a critical value:
This process will be utilized in the taking of verbal or telephone orders and the
calling of results to providers.
All diagnostic tests including laboratory tests and other diagnostic tests to include
any test/ result which require an urgent response must be read back by the person
receiving the results.
SAFETY PRECAUTIONS:
Follow procedures and precautions described in the Saint Michael's Hospital Infection
Control and Hazard Communication manuals, as well as the Saint Michael's Hospital
Chemical Hygiene Plan. Refer to the MSDS for reagent-specific handling guidelines.
ATTACHMENTS:
Critical Value Chart
REFERENCES:
The Joint Commission - National Patient Safety Goals
Ministry Health Care Critical Test Reporting Policy – MSMH and MMGCR (PHY-037)
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ORIGINATING DEPARTMENT/SECTION:
Saint Michael’s Hospital Laboratory
APPROVAL:
___________________________________________________________
Dawn Finch, MT (ASCP) – Director of Laboratory Services
___________________________________________________________
Jason Heese, MD – Medical Director of Laboratory Services
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