Improving Patient Safety by Repeating (Read-Back)
Improving Patient Safety by Repeating (Read-Back)
Reducing the rate of avoidable errors is crucial to patient safety. Telephone calls with misunderstood critical results constitute one area in which opportunities for improvement exist. The aviation industry has dealt with this issue by requiring pilots to repeat instructions received from the air traffic controller. At 3 health care organizations, we tested a program to decrease telephone reporting errors by requiring the recipients of critical results to repeat the message. Of 822 outgoing telephone calls from the laboratory, 29 errors were detected (error rate 3.5%). Calls to physicians had the highest rate of errors (6/95 [5%]). The time required to ask for the information and for the message to be repeated averaged 12.8 seconds per call, which corrected 29 errors. A simple system of repeating telephoned laboratory results has the potential to reduce the risk of medical errors and improve patient safety.
For certain predetermined results, the laboratory is required to have a policy for immediately notifying the patient's caregiver of this critical ("panic value") information. These results might reflect a potentially life-threatening condition that requires rapid treatment such as an extremely low potassium level or the presence of bacteria in the blood. Telephone calls about critical results from laboratory personnel to clinicians are the most common mechanism for such notification and represent one area in which opportunities for improvement exist. The airline industry dealt with the issue of accurate verbal communication by requiring pilots to repeat instructions received from the control tower. The Institute of Medicine has mandated that the current medical system strive to reduce errors associated with medical care. In response to this, the National Coordinating Council to Prevent Medication Errors recommends that recipients read back physician's verbal (telephoned) orders. In 2004, the same requirement will be mandatory for critical calls concerning laboratory results. Therefore, in a collaboration of laboratories, we monitored the accuracy of outgoing telephone results to determine whether this is a useful approach to improve communication of critical information.
Reducing the rate of avoidable errors is crucial to patient safety. Telephone calls with misunderstood critical results constitute one area in which opportunities for improvement exist. The aviation industry has dealt with this issue by requiring pilots to repeat instructions received from the air traffic controller. At 3 health care organizations, we tested a program to decrease telephone reporting errors by requiring the recipients of critical results to repeat the message. Of 822 outgoing telephone calls from the laboratory, 29 errors were detected (error rate 3.5%). Calls to physicians had the highest rate of errors (6/95 [5%]). The time required to ask for the information and for the message to be repeated averaged 12.8 seconds per call, which corrected 29 errors. A simple system of repeating telephoned laboratory results has the potential to reduce the risk of medical errors and improve patient safety.
For certain predetermined results, the laboratory is required to have a policy for immediately notifying the patient's caregiver of this critical ("panic value") information. These results might reflect a potentially life-threatening condition that requires rapid treatment such as an extremely low potassium level or the presence of bacteria in the blood. Telephone calls about critical results from laboratory personnel to clinicians are the most common mechanism for such notification and represent one area in which opportunities for improvement exist. The airline industry dealt with the issue of accurate verbal communication by requiring pilots to repeat instructions received from the control tower. The Institute of Medicine has mandated that the current medical system strive to reduce errors associated with medical care. In response to this, the National Coordinating Council to Prevent Medication Errors recommends that recipients read back physician's verbal (telephoned) orders. In 2004, the same requirement will be mandatory for critical calls concerning laboratory results. Therefore, in a collaboration of laboratories, we monitored the accuracy of outgoing telephone results to determine whether this is a useful approach to improve communication of critical information.
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