I.  PURPOSE
 

This policy establishes procedures in the Los Angeles County Department of Mental Health (DMH) for receiving and reporting Critical Laboratory Values to DMH programs.
 

II.  DEFINITIONS
 

Authorized Personnel: Any DMH MD, DO, PA, NP, Pharm.D., and RN who shall be responsible for receiving Critical Laboratory Value.

Clinic: Any DMH directly operated facility or field-based unit from which laboratory orders may be electronically submitted.

Critical Laboratory Values: Abnormal laboratory values requiring immediate reporting to Authorized Personnel.

Facilitator: Program Manager, clinic Officer of the Day or clerk who shall be responsible for answering call from laboratory and locating authorized personnel to receive call from the laboratory. Facilitators are not authorized to receive lab results from laboratory personnel unless they are credentialed as MD, DO, PA, NP, Pharm.D., or RN.

Readback: The process by which Authorized Personnel verbally verify laboratory values received from the laboratory contractor to ensure reported information has been accurately understood and transcribed.
 

III.  POLICY
 

Laboratory Contractor for the Department shall contact the ordering clinic within 60 minutes of critical laboratory values being resulted. The laboratory contractor shall submit results electronically to the DMH Electronic Prescribing System.

When contact is made outside of business hours, the laboratory contractor shall leave a voicemail describing critical laboratory values at the ordering clinic’s designated telephone number.  The laboratory contractor shall also be responsible for contacting the ordering clinic the next business day to provide the results directly.

The laboratory contractor shall preface voicemails by clearly stating that critical laboratory values are being reported.
 

IV.  PROCEDURES
 

V.  AUTHORITIES
 

Code of Federal Regulations Title 42 Section 493.1291, Standard: Test Report 
 

VI.  ATTACHMENT
 

Hanna, D., Griswold, P., Leape, L. et al. Communicating Critical Test Results: Safe Practice Recommendations. Joint Commission Journal on Quality and Patient Safety. Feb 2005 Vol. 31(2)