Critical laboratory value notification: a failure mode effects and criticality analysis.

Area of Science:

• Healthcare Quality Improvement
• Risk Management in Healthcare
• Clinical Laboratory Science

Background:

• The Failure Mode Effects and Criticality Analysis (FMECA) was employed to enhance the timely reporting and receipt of critical laboratory values (CLVs).
• This initiative focused on outpatients and non-critical care inpatients to improve communication with licensed caregivers.

Purpose of the Study:

• To identify and address systemic issues within the critical laboratory value (CLV) notification process.
• To improve the timeliness and reliability of CLV communication to healthcare providers.

Main Methods:

• A risk prioritization process identified key areas for improvement, including provider contact, patient notification assistance, and off-hours follow-up education.
• Systemic changes included centralizing the CLV notification process, implementing provider databases for follow-up options, and using electronic forms for documentation.

Main Results:

• The average CLV notification time significantly decreased over an eight-month period.
• 100% compliance was achieved for the "read-back" requirement and patient health record documentation.

Conclusions:

• The FMECA successfully transformed the CLV notification program from a high-risk to a low-risk process.
• Proactive risk assessment identified further improvements and ensured compliance with established requirements.