Blog | Tuesday, August 14, 2012

Miscommunicated lab data and its consequences are not unexpected

Read this heart-rending article at the New York Times about NYU’s mistake that let a septic boy out of their ER. Then read this exchange of comments on the article.

tr (Maryland)
As a physician assistant who practices in a major university emergency department, I am confused about one thing. When a patient has seriously high bands or neutrophils, the lab calls back down to the ED to let someone know. Even if the provider who ordered the test has gone off shift, the lab is given to a working provider to follow up with the patient immediately. I have personally called many patients back to the ED for a worrisome lab value, even when I did not see that patient myself. Does NYU not have a similar system? Do they now after this horrific incident?

Jim Dwyer (NYT columnist)
Of the hundreds of comments here, this is probably the most salient. Why was a patient with those alarming blood values not contacted by someone at NYU? What procedures does the NYU lab use when it has these kinds of results? If a patient’s blood shows evidence of a heart attack, the lab will call the doctor directly. Why not with evidence of significant bacterial infection?

Moreover, NYU has declined to discuss how it deals with these kinds of results after a patient has left the hospital. Many people have defended the decision to discharge a patient with fever, rapid pulse and breathing, noting that these are common among children.

To lay people, it is very hard to understand why these sophisticated tests would be ordered but then not read or acted on.

I have more to say to lay people: Lab tests go unreported all the time. The person who orders it doesn’t see it in their queue due to the vagaries of their EMR; a test is ordered by one physician who expects that a second will follow up on it; a lab result, for whatever reason, is classified as abnormal but not urgent or emergent merely because it does not fall within the prespecified ranges of the EMR.

The reason for all of this: our system is fragmented. We lack universal standards for communication of lab results among providers. The case is terrible but the factors underlying it have been publicized time and again.

(For those interested in the lab results in this case, they are here.)

Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews. He is also a poet, journalist and translator in Yiddish and English. This post originally appeared at his blog.