Decreasing Postanalytical Errors with Interpretive Reports
An Interview with Mario Plebani, MD
Mario Plebani, MD, is professor of clinical biochemistry and clinical molecular biology at the University of Padova (Italy) School of Medicine and chief of the department of laboratory medicine at the University-Hospital of Padova. Dr. Plebani has published and lectured extensively on patient-safety topics, including interpretive reports (1,2). For his many contributions to improving patient safety, Dr. Plebani was awarded the 2008 AACC Award for Outstanding Clinical Laboratory Contributions to Improving Patient Safety.
Michael Astion, MD, PhD, conducted this interview.
Q: How do you define misinterpretation of results?
A: Misinterpretation means that the care provider has received the correct result but does not take the correct action on the result.
Q: About what fraction of errors in lab medicine are due to misinterpretation of results?
A: This varies by study, but a rough estimate is that about 5% of errors are related to the misinterpretation of results.
Q: Is misinterpretation of lab test results an important patient-safety problem?
A: Yes. For example, about 33% of delayed or missed diagnoses in the emergency room are due to the incorrect interpretation of tests result (3). Usually these are radiology or lab results. The usual reason for the misinterpretation is lack of knowledge, but system-related factors also play a role.
Q: What are the types of comments that go into an interpretive report?
A: Typically, interpretive reports might include one or more of the following:
- Description of the abnormal result
- Possible reasons for an abnormal result
- Suggestions for further testing
- Statement of need for immediate treatment
Q: What factors favor the use of an interpretive report?
A: Interpretive reports tend to be useful for new or complex tests. They are generally most useful in primary care; however, for specialists, they can be useful for tests outside their specialty. Interpretive reports are easiest to implement when you have communication of lab results to an electronic medical record that is easily accessible to physicians.
Two Examples of Interpretive Comments
For a highly abnormal serum protein electrophoresis:
- Band of restricted mobility migrating in the gamma region. The band is most likely a monoclonal component. The concentration of the band = 2.5 g/dL. Normal gamma globulins are depressed. Recommend contacting the laboratory to add on an immunofixation test if the band has not been previously characterized.
For a culture result showing a pathogenic, multiply-resistant organism (4):
- Infection control precautions required to minimize the risk of transmission to other patients. Pay particular attention to hand washing.
Q: What are some of the new or complex areas of lab testing where interpretive reports are useful?
A: Interpretive reports are useful in a number of areas, including coagulation testing, autoantibody testing, protein electrophoresis, endocrinology, toxicology, and genetic testing. These types of tests tend to be complex, and the interpretation of these tests is often challenging for primary care practitioners or other physicians who are not specializing in these areas.
Q: Do interpretive reports prevent interpretation errors by physicians and improve patient outcomes?
A: There is a growing body of evidence that interpretive tests improve patient outcomes. For example, in a study of interpretive reports in coagulation testing by Laposata and colleagues, more than 70% of physicians using the service responded that the interpretations prevented a misdiagnosis (5). About 60% said the interpretive reports reduced the time to diagnosis. In addition, the reports had an educational value over time in that they appeared to decrease the number of errors related to ordering coagulation tests.
Q: Are there examples in clinical chemistry?
A: Yes. A study by Kilpatrick explored the issue of under-replacement of thyroxine in patients who are hypothyroid (6). The results suggest that interpretive comments related to thyroid testing improve the number of hypothyroid patients who receive appropriate thyroxine replacement.
Q: Do physicians like interpretive reports?
A: Yes, this has been demonstrated in surveys of physicians who receive interpretive reports in coagulation testing, hormone analysis, hematology, and glucose tolerance testing (5,7). This is not surprising, given that surveys of physicians also show that they have a strong desire for decision support for abnormal test results (8).
Q: How do you ensure quality of the interpretative comments?
A: This is an important issue, since interpretive comments can be clinically dangerous if the person providing them has inadequate expertise (9). Therefore, interpretations should be made by clinical experts who are using current evidence and who take into account the patient-specific data available to them. For automated interpretations, a panel of experts can be used to produce standardized remarks and the rules for their use. Another tool helpful in supporting quality is the retrospective auditing of patient charts to monitor the appropriateness of interpretive reports in actual clinical practice.
Found in the Scientific Literature
The Need for Interpretations for Laboratory Testing
Dighe AS, Soderberg BL, Laposata M. Narrative Interpretations for clinical laboratory evaluations. Am J Clin Pathol 2001;116 (Suppl 1):S123-8
- Carraro P, Plebani M. Errors in a stat laboratory: types and frequencies 10 years later. Clin Chem 2007;53:1338–1342.
- Plebani M. What information on quality specifications should be communicated to clinicians, and how? Clin Chim Acta 2004; 346:25–35.
- LaKachalia A, Ghandi TK, Puopolo AL, et al. Missed and delayed diagnosis in the emergency department: a study of closed malpractice claims from 4 liability insurers. Ann Emerg Med 2007; 49: 196–205.
- Cunney R, Aziz HA, Schubert D, et al. Interpretative reporting and selective antimicrobial susceptibility release in non-critical microbiology results. J Antimicrob Chemother 2000; 45: 705–708.
- Laposata ME, Laposata M, Van Cott EM, et al. Physician survey of a laboratory medicine interpretive service and evaluation of the influence of interpretations on laboratory test ordering. Arch Pathol Lab Med 2004;128:1424–1427.
- Kilpatrick ES. Can the addition of interpretative comments to laboratory reports influence outcome? An example involving patients taking thyroxine. Ann Clin Biochem 2004; 41:227–229.
- Barlow IM. Are biochemistry interpretative comments helpful? Results of a general practitioner and nurse practitioner survey. Ann Clin Biochem 2008; 45:88–90.
- Poon EG, Gandhi TK, Sequist TD, et al. “I wish I had seen this test result earlier!”: Dissatisfaction with test result management systems in primary care. Arch Intern Med 2004;164:2223–2228.
- Lim EM, Sikaris KA, Gill J, et al. Quality assessment of interpretive commenting in clinical chemistry. Clin Chem 2004; 50:471–472.