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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, 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 3, 2018
  • Shipment B: March 4, 2019
  • Shipment C: June 3, 2019
  • Shipment D: September 3, 2019

Additional Information

Participants in the Q-TRACKS program receive:

  • Users Guide
  • Templates and instructions for data collection
  • Quarterly reports that include fingerprint clusters, customer-defined groups, and all institution comparisons
  • Peer directory

Q-TRACKS activities meet the American Board of Pathology MOC Part IV Practice Performance Assessment requirements.

For Comprehensive Collection of Tools, see Quality Management Tools.


 
Select Q-PROBES and Q-TRACKS studies to support your quality improvement initiatives.
Preanalytic
Analytic
Postanalytic
Anatomic Pathology
Clinical Pathology
Turnaround Time
Patient Safety
Microbiology
Transfusion Medicine
Chemistry/ Hematology
Customer Satisfaction
Q-PROBES
Technical Staffing Ratios (QP191)
Opioid Drug Testing Stewardship (QP192)
Expression Rates in Invasive Breast Carcinoma (QP193)
The Impact of Pathologist Review on Peripheral Blood Smears (QP194)
Q-TRACKS
Patient Identification Accuracy (QT1)
Blood Culture Contamination (QT2)
Laboratory Specimen Acceptability (QT3)
In-Date Blood Product Wastage (QT4)
Gynecologic Cytology Outcomes: Biopsy Correlation Performance (QT5)
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).