The Joint Commission - Quick safety issue 52: Advancing safety with closed-loop communication of test results (17 December 2019)

Summary

Closed-loop communication—when every test result is sent, received, acknowledged and acted upon without failure—is essential to reduce diagnostic error. This requires multiple parties within the healthcare system working together to refer, carry out tests, interpret the results and communicate them in language the patient can understand. If abnormal test results are not communicated in a timely manner, it can lead to patient harm.

This Quick Safety case study looks at the case of a 47-year-old school teacher who had a screening mammogram. The radiologist identified a suspicious area of calcifications, which required follow up. The patient’s GP was not on the same electronic medical record (EMR) as the imaging centre and, because of front office changes, missed the notification to follow up. The patient was told that the radiologist would contact her if the results were abnormal and therefore assumed she was okay. A year later when seeing her GP, the patient was told that she needed follow-up testing and that she had stage 3 cancer. Her lesion had grown significantly, and she now required surgery, chemotherapy and radiation for advanced breast cancer.

The case study suggests safety actions that should be considered to prevent this error from happening again.