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Say It Again

Kerm Henriksen, PhD; Kendall K. Hall, MD, MS | June 1, 2011
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The Case

A 72-year-old man was admitted to the hospital with community-acquired pneumonia and hyponatremia. During his third hospital night, the on-call physician was contacted by the charge nurse, who had received a "critical panic value" call for a potassium level of 2.2 (normal=3.5-5). The physician began writing for an EKG and immediate potassium supplementation. While writing the orders, he quickly glanced in the electronic health record to see what the patient's previous potassium levels were. To his surprise, he discovered that the patient didn't have a potassium level listed in the computer for that day; nor was there evidence that one had been ordered or drawn.

After calling the charge nurse back, they discovered the panic value was intended for a different patient with a similar last name on the unit. It was unclear if a "read-back" occurred between the lab tech and the charge nurse, who was covering for the patient's bedside nurse while the latter was on her break. Luckily, this was a "near miss"—the patient did not receive the unnecessary and potentially dangerous potassium supplementation and had an otherwise uneventful hospital course.

The Commentary


The case involves mistaken patient identity and raises concern about whether the lab technician and charge nurse were somehow remiss in not engaging in a read-back as part of their information exchange. Read-backs are used to help ensure that a message is understood by the receiver in the way it was intended by the sender. Most of us have experienced read-backs in daily life, when vendors repeat credit card information for purchases made over the phone or our favorite Chinese carry-out repeats our order back before ending the call—both with remarkable consistency. Yet, it is the high-stakes industries—aviation and the military in particular—that study communication extensively, use standardized protocols where needed, and continually investigate the nuances of communication exchanges.(1,2)

In health care, it is also the high-stakes areas—emergency medical services (3), emergency departments (4), surgery (5-7), laboratory test results (8,9), and patient handoffs (10)—in which the value of read-backs has been emphasized and studied, even though communication failures are ubiquitous in any setting. Read-backs have their greatest potential value when there is background noise or other environmental distractions, when misinterpretation might result from sound-alike letters or words, when numbers or letters might be missed or reversed, or when there is ambiguity in the words used.

Communication & Safety: The Joint Commission's Efforts

Communication failure continues to be one of the leading root causes of sentinel events reported to The Joint Commission (TJC).(11) As far back as 2002, they were concerned about untimely, incomplete, or inaccurate communication practices resulting in delays of treatment. This led to recommendations for a read-back or verification when verbal orders are necessary. In 2004, as part of its second National Patient Safety Goal (NPSG) that focused on effective communication among providers, TJC specified that individuals receiving information write down (or enter into a computer) the complete order or test result, read it back, and finally require the individual who gave the order or test result to confirm the information was read back correctly.

The case involves a serious near miss of mistaken identity, underscoring the relevance of read-backs and the NPSG goal of improving the accuracy of patient identification. Problems associated with inadequate communication and patient identity often overlap and are multi-factorial in nature. Rather than unnecessarily impose separate protocols on facilities to achieve the two NPSGs, the Table illustrates how an integrated "best practice" satisfies both goals simultaneously; that is, engaging in a read-back to ensure that lab values are communicated accurately and providing two patient identifiers to avoid mistaken patient identity.

Patients will continue to be at risk unless roles and responsibilities are clearly delineated among providers with respect to how critical information should be sent, received, recorded, and confirmed. When a patient's bedside nurse is unavailable or on a break, policy needs to be unambiguous as to who owns information and what they should do with it. Whoever assumes care of the patient—even during a 10-minute break—needs to have a clear understanding of what their responsibilities are regarding critical information about the patient.

Embedding Read-Backs into Workflow

Despite the common sense notion of using read-backs to improve communication, simply issuing a requirement for them is not the same thing as ensuring compliance or commitment to it. While deceptively simple, the implementation of and adherence to read-backs can be challenging for harried providers. How well established are the critical values that need to be reported? To what laboratory tests and services do they apply? Without a carefully specified policy that is seamlessly integrated into the workflow of providers, read-backs will not occur or will be performed in a perfunctory manner. Moreover, the policy needs to be sensitive to contextual factors in the units where it is implemented. To ensure that policy is informed by clinical reality and unit-level contextual factors, we recommend that well-meaning policy pronouncements first undergo testing in a diverse range of care settings for which they were intended. Otherwise, they might overlook important work-related considerations and meet with needless resistance.

In terms of integrating the process into workflow, the right thing to do also needs to be the easy thing to do. The sending, receipt, and confirmation of critical information that read-backs provide should be designed into the interfaces or computer screens of senders and receivers. Designers of medical software would be wise to include a record-and-confirm function in the electronic products they sell hospitals. At the same time, users and purchasers of these products need to make their needs known to vendors. When information is taken in a non-computerized environment, procedures need to be developed for reliably integrating the receipt and uploading of information into workflow pathways. Reliably recording the information exchange provides a platform for monitoring and ensuring that exchanges take place as they should. Periodic monitoring can be supplemented with floor observations and interviews to see how well new procedures are working and to seek feedback for improving the process.

Limitations of Read-Backs

A read-back with appropriate patient identifiers might have averted the near miss in this case, but it does not guarantee safety.(12) Repetitive, routine tasks are subject to cognitive drift; that is, performing tasks half-heartedly or with insufficient focus. Rather than relying blindly on the read-back, providers still need to exercise heightened sensitivity to the unexpected during exchanges of critical information. High reliability organizations—a goal for health care organizations to reach—are ever mindful of the unexpected, and fully recognize the importance of resilience and sensitivity to operations.(13,14)

Gaining buy-in and successfully implementing read-backs is also easier when there is an organizational culture that places patient safety as a core value of the highest order. New procedures or protocols are easier to implement when there is a recognized need for change; when organizational leadership (including local unit-based leaders) is actively involved; when conditions of trust and information sharing exist; and when the expertise of front-line personnel is called upon early to help integrate acceptable changes into the workflow.(15)

In summary, read-backs can be an effective communication tool but they may not yield their desired effectiveness unless thoughtfully integrated into existing workflows with attention to local contextual and cultural factors. Communication failures are unfortunately embedded into the wider web of our health care systems. The appeal of a well-intended "fix" can be short-lived if the interdependencies among information needs, communication processes, and consequences of care are poorly understood and neglected.(15)

Take-Home Points

  • Read-backs help ensure that a message is understood by the receiver in the way intended by the sender.
  • Successful implementation of read-backs is most likely to occur when integrated into the workflow of providers.
  • Read-backs do not guarantee safety; providers still need to be sensitive to unexpected ways exchanges of critical information can fail.
  • Acceptance of new protocols occurs when there is involvement and ownership at the local-unit level rather than solely imposed externally.

Kerm Henriksen, PhD Human Factors Advisor for Patient Safety Agency for Healthcare Research and Quality

Kendall K. Hall, MD, MS Medical Officer for Patient Safety Agency for Healthcare Research and Quality


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Table. Proposed "Best Practice" for a read-back of critical lab values

Lab Tech: Hello. This is Larry Hastings in the lab. Are you responsible for Harold Jackson, age 72?
Charge Nurse: Yes, I am.
Lab Tech: I have a critical value to report that I need you to record and repeat the information back to me. The potassium level for Harold Jackson, birth date December 17th, 1938, is 2.2.
Charge Nurse: Okay, I've recorded it. The potassium level for Mr. Harold Jackson, birth date December 17th, 1938, is 2.2.
Lab Tech: Correct. Thanks for the confirmation.
This project was funded under contract number 75Q80119C00004 from the Agency for Healthcare Research and Quality (AHRQ), U.S. Department of Health and Human Services. The authors are solely responsible for this report’s contents, findings, and conclusions, which do not necessarily represent the views of AHRQ. Readers should not interpret any statement in this report as an official position of AHRQ or of the U.S. Department of Health and Human Services. None of the authors has any affiliation or financial involvement that conflicts with the material presented in this report. View AHRQ Disclaimers
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