NQF Updates Reportable Events List, Highlights Communication Gaps

Officials at the National Quality Forum are calling on physicians to do a better job communicating key clinical findings such as laboratory and pathology results.

As part of its updated list of serious reportable events, the NQF added a new adverse event for hospitals to track and report on: patient death or serious injury resulting from a failure to follow up or communicate laboratory, pathology, or radiology test results. The event takes into account findings that need to be communicated immediately like a chest x-ray that shows an acutely collapsed lung, as well as other important findings such as an x-ray that reveals a growing lung mass.

In June, the NQF released the updated list of 29 adverse health care events that it considers to be largely preventable, such as wrong site surgery and stage 3 or 4 pressure ulcers acquired post admission.

This time around the list includes four new events ranging from death or serious injury associated with bringing a metallic object into the MRI area to death or serious injury due to the loss of an irreplaceable biologic specimen.

The list, which was originally released in 2002 and last updated in 2006, is designed as a set of voluntary, consensus standards to be used in public reporting programs. More than half of the states currently use the list as the basis for their public reporting programs.

For hospitalists, a focus on better communication of lab, pathology, and radiology results is critical, said Dr. Janet Nagamine, a hospitalist at Kaiser Permanente Hospital in Santa Clara, Calif., and a mentor for the Society of Hospital Medicine’s Project BOOST. Project BOOST aims to reduce hospital readmissions by improving the hospital discharge process.

Literature published in the last few years shows that health care providers don’t have the best track record when it comes to communicating test results, as well as following up on recommended tests and referrals, she said. A 2005 study of patients discharged from hospitals in Boston found that of the 2,033 test results returned after discharge, physicians were unaware of 62% of the results. Of those, 37% had "actionable" results and 12% required "urgent action" (Ann. Intern. Med. 2005;143:121-8). And in terms of recommended work-ups, another study found that of 240 tests and referrals recommended by physicians in the hospital, about 36% were not completed (Arch. Intern. Med. 2007;167:1305-11).

Hospitalists will face challenges as they try to tackle these problems, said Dr. Gregg S. Meyer, cochair of NQF’s Serious Reportable Events Steering Committee. The first hurdle is that many patients have tests conducted during their hospital stay, but the results are pending at the time of discharge. The issue becomes who is responsible for obtaining those results and following up on them with the patient, said Dr. Meyer, who is also the senior vice president for quality and safety at Massachusetts General Hospital in Boston.

Another challenge is the communication between the hospitalist and the primary care physician, Dr. Meyer said. For example, a hospitalist may leave a phone message for a primary care physician about an important lab result, but what if the hospitalist leaves the message at the wrong place? Physicians need to have a system in place that guarantees "closed-loop communication," where the hospitalist would know that the message was received on the other end, Dr. Meyer said.

"Just leaving a phone message or just sending a fax or just sending a letter with something important like this may not be enough," he said.

Massachusetts General Hospital has used electronic tools to help tackle the problem of closed-loop communication. For instance, if a radiologist sees a critical finding, like a collapsed lung, he or she pages the appropriate physician immediately and documents that in the electronic system along with when the page was answered.

Another strategy is to use the discharge process to prompt hospitalists to follow up on tests, Dr. Nagamine said. At her hospital, the discharge summary includes the studies that were completed, those that are pending, and the ones that need to be ordered. "The real key is embedding it into your processes," she said.

Hospitalists also need to develop working relationships and agreements between themselves and the primary care physicians they work with to figure out whose job it is to order necessary follow-up tests, Dr. Nagamine said.