A portion of clinical error results from the misinterpretation of laboratory data. Powsner et al reported that surgeons misunderstood 30% of pathology reports.
Whether one communicates test results electronically, by fax, or on paper, one should periodically review the content and layout of the reports to make sure they are as useful as possible. Are the clinicians and caregivers who receive the reports getting the information they need to treat the patient? Is the information clear, accurate, and laid out in such a way that the readers don’t have to struggle to comprehend the data?
Easy Places to Start
Periodically (at a minimum, annually) review all versions of your reports, with the goal of increasing their quality, accuracy, and interpretability. Also review your reports whenever there has been a readability complaint or after a change in testing methodology.
• Make the font size large enough. The report should be quickly and easily readable, at arm’s length, in imperfect lighting, by someone wearing bifocals. The smaller the font, the greater the likelihood of misreading the value.
• Perform legibility tests:
o Fax a sample of your reports to yourself. Are the numbers and text small and fuzzy or are they clear and legible? To simulate what your customers may see, repeat the test using the fax you just received.
o If your reports are being read via a hospital or practice management computer system, verify that your reports display appropriately and legibly on the systems the physicians are using to read the reports.
• Check for complete patient information, including full name, date of birth, and gender.
• Check for specimen source/type, reference ranges or target ranges, and flags ( if indicated).
• Check that Medical Director, facility name, and contact details are on every page of every report.
• Verify any calculated results.
• Check for coding and billing information and any pay-for-performance indicators—e.g., PQRI codes.
• Review the clarity of the interpretation and any comments—e.g., are interpretations clearly associated with the related result?
• Check for reference to prior results, if any. If the result is a critical value, make sure the report includes documentation of appropriate communication—e.g., who notified whom? When? How?
Digging Deeper
There is a lot at stake in one simple lab report. In one study, surgeons misunderstood pathologists’ reports 30% of the time (Powsner). These additional steps can help improve the usability of your reports:
• Standardize the “look and feel” of your results to make them easier to interpret. Putting the same information in the same place, time after time, trains your readers to locate what they are looking for.
• Don’t crowd the data on the page; use sufficient white space to separate columns and lines of numbers.
• All the text should be a good distance from the margins, so no text gets cut off when printing or faxing.
• Enhance your reports with electronic tools such as embedded links to references or other background information—even photos.
• Implement synoptic reports.
• If you use paper charts, consider how you present summary reports and how frequently they are replaced.
• Ask the report recipients for feedback about the information and its presentation. How could you improve the quality and usability of the reports?
Tell the Story
After you have implemented your reporting changes, toot your horn with the administration. Show them the before and after test result reporting formats. Share the metrics of the improvements, including the number of times the improvements will be encountered by clinicians, and the resulting positive impact on patient care.
Reference : College of Americal Pathologist website.(www.cap.org )
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