Background: Patient safety relies in part on timely review of laboratory and other results by appropriate providers. At our quaternary care, free-standing children’s hospital, providers were directly notified only of “critical” results (<1% of all lab results). While inpatient labs resulted prior to discharge are actively reviewed in the electronic medical record (EMR) by inpatient providers, there was no “closed loop laboratory” system to ensure inpatient labs resulted post-discharge – or any outpatient labs – were reviewed by appropriate providers. Providers devised numerous workarounds to manually track results, and we experienced several sentinel safety events due to delays in reviewing results. Our aim was to ensure that within 12 months, >80% of all non-critical lab results were endorsed within 3 calendar days by the appropriate provider.
Methods: Our interprofessional improvement team represented outpatient and inpatient providers, laboratory medicine, information technology, risk management, project management, and administrative leadership. Using LEAN principles and quality improvement methodology, and leveraging existing EMR functionality, we designed a streamlined process to route labs electronically and document provider review. We first defined “appropriate provider roles” for outpatient tests as the ordering attending and service group and for inpatient tests resulted post-discharge (regardless of when in the admission a test was ordered) as the dischargeattending and service group. We then devised a system to route lab results within the EMR to the appropriate provider (with a daily email prompt) and to a service “pool,” through which other service members could also access their group’s labs. Though anyone could view a result, it could only be “endorsed” by the appropriate provider role. These providers were then expected to act accordingly, e.g. change management, update the patient/ family, and/or forward results to another involved provider.
Results: We piloted the program at a single, large outpatient site, where compliance has risen to 67% (3 day) and 93% (overall). We then spread to the inpatient setting, where compliance has increased to 63% (3 day) and 86% (overall). Importantly, no serious safety events due to missed lab results have been reported. Further, provider feedback has been overall positive, especially regarding the streamlined workflow, relief at no longer missing lab results, and an enhanced ability to communicate with other involved providers.
Conclusions: Applying LEAN principles and quality improvement methodology, and leveraging existing EMR functionality, we designed a streamlined “closed loop lab” system for outpatient labs and inpatient labs resulted post-discharge. We continue with process enhancements to improve routing accuracy, and with service- and individual-level feedback to achieve 100% compliance. We are now expanding our successes to other results (i.e. surgical pathology, anatomic pathology, radiology) and settings (i.e. emergency department, other outpatient clinics).
