Report results; avoid risk
Medical Laboratory Observer, May, 2004 by Barbara Harty-Golder

http://www.mlo-online.com/articles/0504/0504liability.pdf

Q What is the correct way to deal with results for incorrect tests ordered
on a patient? In our hospital system, some labs delete the test, removing
the result from the computer patient report and the next printed cumulative
report. Some labs leave the result in and issue a credit to the patient.
What if the error is discovered after the patient is discharged? Two
examples: A vancomycin trough was ordered and resulted on a patient; the
correct testing should have been tobramycin. Once, a B-type natriuretic
peptide result was entered--completely inconsistent with previous/subsequent
testing. An instrument-log review did not show any testing on that sample or
any other testing with the particular result reported.

A The correct response depends on the definition of "incorrect test." Your
examples outline two different situations with very different
risk-management implications. In any case of testing error, it is incumbent
upon the lab to correct the mistake, report the proper results to the chart,
and directly notify the physician in case the error has an effect on patient
care. Depending on the situation, there can be several additional and
appropriate risk-management responses.

If an incorrect test has been properly performed (reporting a perfectly
valid vancomycin level when a tobramycin level was ordered), first collect
the specimen for running the correct test, especially if (as in the case
with peak and trough measurements) the value is time-sensitive. If the wrong
test has a correctly reported value, there is no pressing need to remove the
value from the medical record; however, a notation to that effect should be
made, and the patient should not be charged. A good risk-management argument
is that the results should be left in the medical record because once seen,
they may be relied on by the physician if they have unexpected relevance to
the patient's care. Culling the result from the record here might cause
confusion later, especially if a lawsuit arises and lawyers go through the
chart with a fine-toothed comb.

When the test is ordered properly but the result is invalid (e.g., performed
on the wrong sample, operator error, or simple unexplained testing glitch),
it is still imperative to get the right test results into the record as soon
as possible, identifying the new results as corrected values and confirming
that the patient is not charged twice.

Reporting invalid results raises a far more serious risk-management
question, especially when it involves clinically sensitive tests on which
patient management will be based. Purging the invalid result from the record
may confuse a review of the case later, if--again--a lawsuit arises and
lawyers question why certain treatment decisions were made on the basis of
values no longer in the chart. In some states, if chart alterations are not
done clearly and appropriately, the lab might be open to charges of
fraudulent medical-record alteration. If the value is left in the record
without clear notification of error--even if a new result is posted--an
unwary physician might mistake the old, invalid results for the correct
ones.

Most institutions have policies--which need regular review--for correcting
such errors. Legal consultation comparing such a policy to state
record-keeping requirements is a good idea. My preference? Remove the
offending incorrect report, issue a clearly marked replacement with the
correct value, and issue an incident narrative to the medical record's
progress notes, indicating the date/time of the initial incorrect
report/initial incorrect reported value, and the date/time of the corrected
report/corrected value.

An excellent idea is to notify by telephone the hospital and
outpatient-testing personnel, and the attending physician when the error is
discovered and again when the correction is made, including those
notification(s) in the narrative correction. If the error is discovered
after the patient is discharged, it is particularly important to notify the
physician directly, rather than just correcting the record.

This assures that the erroneous result and its value are still in the
record, but makes it less likely that a casual reading will result in
treatment decisions based on the original report left in the "lab results"
section. Here, because the physician may have relied on the incorrect value
between the time of initial reporting and correction, it is crucial not to
cull the incorrect value without leaving a trace. Imagine initially
reporting a pregnancy test as negative--clearing the way for the use of
medicine or radiological procedures that should be avoided on a pregnant
woman--only to find out later that the test was actually positive. For
medical-legal purposes, having some record of the initial, if erroneous,
result would be important for the physician's defense in a subsequent
lawsuit--even though it points a finger directly at the lab.

No matter what the genesis of the error, once found, the lab should
investigate, to determining how the mistake was made, and correcting any
policy, procedure, or system flaws that led to it. If it happened once, it
can happen again!

By Barbara Harty-Golder, MD, JD

Barbara Harty-Golder, is a pathologist-attorney consultant in Chattanooga,
TN, maintains a law practice with a special interest in medical law. She
writes and lectures extensively on healthcare law, risk management, and
human resource management.

This column is intended to provide risk management and human resource
management education; it is not intended to provide specific legal advice.
If you require legal advice, the services of an attorney should be sought.
Dr. Harty-Golder welcomes your questions, which can be sent to her at
toadehall@....


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