Critical result reporting

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A critical result is a result which “represents a pathophysiological state at such variance with normal as to be life threatening unless something is done promptly and for which some corrective action could be taken.”[1] A system to communicate critical lab results was first described by Lundberg in the early 1970’s.[2]

Critical result notification is required under the Clinical Laboratory Improvement Amendments [3] and is an accreditation standard for the College of American Pathologists[4] and the Joint Commission on Accreditation of Hospitals. The Joint Commission lists the reporting of critical results of tests and diagnostic procedures as one of its National Patient Safety Goals.[5] Guidelines for communication of critical radiology findings have also been outlined by the American College of Radiology. [6]


A recent systematic review suggests that missed critical results are a significant problem associated with serious patient outcomes but the extent is difficult to ascertain given the heterogeneity of the literature. [7] Missed radiology results are an important contributor to mortality, disability, and medical liability. [8]

Evidence suggests that there are delays to the management of critical results and this is, in part, related to difficulties contacting the provider. [9, 10] Traditionally, the lab is responsible for contacting the provider or care unit with the critical value; however, two other methods have emerged:

1. Automated notification. A critical value will trigger an automated alert being sent to the provider via pager, mobile phone, e-mail or other device.

2. Call centre. A critical value is referred to a centralized call centre responsible for contacting the responsible provider.

In a recent review of laboratory best practices, call centres were recommended as a best practice. While automated notification systems demonstrated a trend to improving response times, evidence was insufficient to recommend it as a best practice. [11]

It is important to note that evidence appears conflicting whether the use of new technology and improved notification actually leads to earlier intervention. [12-14]

Components of Critical Value Reporting

The Massachusetts Coalition for the Prevention of Medical Errors and the Massachusetts Hospital Association developed recommendations for effective communication of critical test results [15]:

1. Identify who should receive the results.

2. Identify who should receive the results when the ordering provider is not available.

3. Define what test results require timely and reliable communication.

4. Identify when test results should be actively reported to the ordering provider and establish explicit time frames for this process.

5. Identify how to notify the responsible provider(s) including ensuring acknowledgement of the result by the provider who will take action.

6. Establish a shared policy for uniform communication of all types of test results (laboratory, cardiology, radiology, and other diagnostic tests) to all recipients including standardized “read-back” techniques.

7. Design reliability into the system such as specific procedures to address high-risk situations (ex. transitions of care, discharge).

8. Support and maintain the systems (ex. monitoring effectiveness of the system).

9. Support infrastructure development such as the use of novel communication technology and improved clinical decision support.

Successful implementation of critical result reporting requires good knowledge of the clinical context, clear policies, strong engagement of stakeholders, and rational use of new technologies. [16, 17]


1. Lundberg, G.D., Critical (panic) value notification: an established laboratory practice policy (parameter). Jama, 1990. 263(5): p. 709.

2. Lundberg, G., When to panic over abnormal values. MLO Med Lab Obs, 1972. 4(1): p. 47-54.

3. US Government Printing Office. Clinical laboratory improvement amendments regulations [42 CFR 493.1251 subpart b(11 and 13)]

4. CollegeofAmericanPathologists.LaboratoryGeneral Checklist [components GEN.41320, GEN.41330, and GEN.41340]. Available at Accessed August 6, 2010.

5. The Joint Commission. The National Patient Safety Goals. (NPSG.02.03.01). 2014. Available at Accessed 25 April, 2014.

6. American College of Radiology. The ACR practice guideline for communication of diagnostic imaging findings. (Revised 2010, Resolution 11). Reston, VA: American College of Radiology; 2010:1–6.

7. Callen, J., et al., The safety implications of missed test results for hospitalised patients: a systematic review. BMJ Qual Saf, 2011. 20(2): p. 194-9.

8. Saber Tehrani, A.S., et al., 25-Year summary of US malpractice claims for diagnostic errors 1986-2010: an analysis from the National Practitioner Data Bank. BMJ Qual Saf, 2013. 22(8): p. 672-80.

9. Kuperman, G.J., et al., How promptly are inpatients treated for critical laboratory results? Journal of the American Medical Informatics Association, 1998. 5(1): p. 112-119.

10. Moore, C.R., et al., Follow-up of markedly elevated serum potassium results in the ambulatory setting: implications for patient safety. Am J Med Qual, 2006. 21(2): p. 115-24.

11. Liebow, E.B., et al., Effectiveness of automated notification and customer service call centers for timely and accurate reporting of critical values: a laboratory medicine best practices systematic review and meta-analysis. Clin Biochem, 2012. 45(13-14): p. 979-87.

12. Etchells, E., et al., Real-time clinical alerting: effect of an automated paging system on response time to critical laboratory values--a randomised controlled trial. Qual Saf Health Care, 2010. 19(2): p. 99-102.

13. Singh, H., et al., Timely follow-up of abnormal diagnostic imaging test results in an outpatient setting: are electronic medical records achieving their potential? Arch Intern Med, 2009. 169(17): p. 1578-86.

14. Lin, J.J. and C. Moore, Impact of an electronic health record on follow-up time for markedly elevated serum potassium results. Am J Med Qual, 2011. 26(4): p. 308-14.

15. Hanna, D., et al., Communicating critical test results: safe practice recommendations. Jt Comm J Qual Patient Saf, 2005. 31(2): p. 68-80.

16. Ti, L.K., et al., Innovative strategy for effective critical laboratory result management: end-to-end process using automation and manual call centre. BMJ Qual Saf, 2012. 21(8): p. 657-62.

17. Singh, H. and M.S. Vij, Eight recommendations for policies for communicating abnormal test results. Jt Comm J Qual Patient Saf, 2010. 36(5): p. 226-32.

Submitted by Rick Mah