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CRITICAL VALUES REPORTING - QT10
QT10
Laboratories commonly refer to critical values as results requiring immediate notification to the physician or caregiver for necessary patient evaluation or treatment. Regulations from agencies and accreditors such as the CMS, The Joint Commission (National Patient Safety Goal NPSG.02.03.01), and the CAP Checklist statement (GEN.20316, COM.30000, COM.30100) mandate that laboratories develop and implement an alert system for critical values. Use this monitor to document compliance with your laboratory's alert plan.
Objective
Evaluate the documentation of successful critical values reporting in the general laboratory for inpatients and outpatients
Data Collection
On a monthly basis, participants will evaluate 120 inpatient and 120 outpatient critical values. Data collection will include general chemistry, hematology, and coagulation analytes on the critical values list. Retrospectively, participants will record the total number of critical values monitored and the number with documentation of successful notification. In addition, participants will provide the number of critical values that were not communicated within three hours, the number of failed notifications due to laboratory oversight, and the number of successful notifications to licensed caregivers. This monitor will exclude critical values for cardiac markers, drugs of abuse, therapeutic drug levels, urinalysis, blood gases, point-of-care tests, and tests performed at reference laboratories.
Performance Indicator
Total critical values reporting rate (%)
Inpatient critical values reporting rate (%)
Outpatient critical values reporting rate (%)
Failed notification (< 3 hours) rate (%)
Shipping Schedule
Shipment A: December 4, 2023
Shipment B: March 11, 2024
Shipment C: June 10, 2024
Shipment D: September 9, 2024
Additional Information
Participants in this program receive:
User Guide
Templates and instructions for data collection
Quarterly reports that include fingerprint clusters, customer-defined groups, and all institution comparisons
Peer directory
Quality Management Tools activities meet the American Board of Pathology MOC Part IV Practice Performance Assessment requirements.
Satisfaction with Outpatient Specimen Collection (QT7)
✓
✓
✓
✓
Stat Test Turnaround Time Outliers (QT8)
✓
✓
✓
✓
✓
✓
Critical Values Reporting (QT10)
✓
✓
✓
✓
✓
Troponin Turnaround Times (QT15)
✓
✓
✓
✓
✓
✓
✓
✓
Corrected Results (QT16)
✓
✓
✓
✓
✓
✓
✓
✓
Outpatient Order Entry Errors (QT17)
✓
✓
✓
✓
✓
✓
✓
*The CAP requires accredited laboratories to have a quality management plan that covers all areas of the laboratory and includes benchmarking key measures of laboratory performance (GEN.13806, GEN.20316, COM.04000). The Joint Commission requires accredited hospitals to regularly collect and analyze performance data (PI.01.01.01, PI.02.01.01). CLIA requires laboratories to monitor, assess, and correct problems identified in preanalytic, analytic, and postanalytic systems (§493.1249, §493.1289, §493.1299).
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