A 25-year-old woman in her first pregnancy was seen at 33 weeks' gestation with new onset hypertension and a blood pressure of 140–150/90 mm Hg. Urinalysis revealed 2+ protein (100 mg/dL) on a random urine dipstick, and a urine protein/creatinine ratio was 0.5 mg/dL (normal up to 0.3 mg/dL). With a potential diagnosis of preeclampsia (new onset hypertension and proteinuria during pregnancy), she was admitted to the hospital for observation, fetal testing, and laboratory studies, including a 24-hour urine protein collection. In the absence of proteinuria, this syndrome is considered gestational hypertension, a less serious diagnosis, managed as an outpatient with either observation or antihypertensive medications.
The laboratory studies and 24-hour urine collection for proteinuria were checked by the obstetrics/gynecology (OB/GYN) resident in the hospital electronic medical record (EMR), where they were reported as normal. Assuming a diagnosis of gestational hypertension, the resident initiated discharge planning, including management with antihypertensive medications. However, the attending physician, noting the inconsistency between the dipstick proteinuria and negative result on the 24-hour urine, rechecked the laboratory results. Upon recheck, he observed that the laboratory had amended the report confirming the 24-hour protein collection was actually elevated and abnormal, confirming the diagnosis of preeclampsia. The patient's discharge was canceled.
In this instance, the amended laboratory result was recognized prior to discharge and a new management plan, which involved continued observation in the hospital, was implemented. No harm was done to the patient. She remained in the hospital for 5 days and was induced at 34 weeks for worsening preeclampsia. The mother and infant ultimately did well.
On later review, it was determined that the nature of this error centered upon the communication of an amended test or report. Although this hospital's policy mandated that the inpatient unit be notified about amended laboratory reports, notifying the physician was not part of the mandate. Consequently, the ordering physician was not alerted to the change in the laboratory report.
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Figure 1. Communicating critical test results: Creating a fail-safe process.(5)
© American College of Physicians: Gandhi TK. Fumbled handoffs: one dropped ball after another. Ann Intern Med. 2005;142:352-358. Reprinted with permission.
Figure 2. Developing a fail-safe communication system.(6)
© Joint Commission Resources: Hanna D, Griswold P, Leape LL, Bates DW. Communicating critical test results: safe practice recommendations. Jt Comm J Qual Patient Saf. 2005;31:68-80. Reprinted with permission.