Original Article

Improving Critical Value Read-Back Failure Rate by Modifying the Notification Procedure

Authors: Shauna Harris, MD, William Leech, BS, Daniel Matienzo, BS, Sonia Berrios Villanueva, MPA, Joshua Fogel, PhD, Maggie Tetrokalashvili, MD, John Riggs, MD


Objectives: The aim of the study was to determine whether a system process change improved successful read-back of critical values by the appropriate provider.

Methods: The study implemented a system process change of switching the “first call” physician from the admitting physician to the most recent document writer. Data were compared before (N = 301) and after the intervention (N = 201). Predictor variables included patient factors, physician factors, and environmental factors. The outcome variables measured were successful read-back within 5 and 30 minutes.

Results: Read-back failure within 5 minutes was significantly reduced (P < 0.001) from preintervention (49.5%) to postintervention (31.3%). Multivariate logistic regression showed reduced odds for read-back failure postintervention (odds ratio [OR] 0.46, 95% confidence interval [CI] 0.31–0.67, P < 0.001) and increased odds for read-back failure for patients of Hispanic race/ethnicity (OR 1.77, 95% CI 1.09–2.89, P < 0.05). Read-back failure within 30 minutes did not significantly change. Multivariate logistic regression showed that an increased number of telephone calls were associated with an increased odds for read-back failure (OR 3.12, 95% CI 2.13–4.57, P < 0.001).

Conclusions: We recommend the use of the physician who has most recently engaged with the patient as documented in the medical record for the daily note as the primary source of contact for reporting critical values.
Posted in: Primarily Safety/Quality Improvement1

This content is limited to qualifying members.

Existing members, please login first.

If you have an existing account please login now to access this article or view your purchase options.

Purchase only this article ($15)

Create a free account, then purchase this article to download or access it online for 24 hours.

Purchase an SMJ online subscription ($75)

Create a free account, then purchase a subscription to get complete access to all articles for a full year.

Purchase a membership plan (fees vary)

Premium members can access all articles plus recieve many more benefits. View all membership plans and benefit packages.


1. The Joint Commission. National Patient Safety Goals. http://www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals/06_npsg_facts.htm. Accessed October 16, 2018.
2. The Joint Commission. National Patient Safety Goals effective January 2017: laboratory accreditation program. www.jointcommission.org/assets/1/6/NPSG_Chapter_LAB_Jan2017.pdf. Accessed October 16, 2018.
4. Callen J, Georgiou A, Li J, et al. The safety implications of missed test results for hospitalised patients: a systematic review. BMJ Qual Saf 2011;20:194-199.
5. Hussain S. Communicating critical results in radiology. J Am Coll Radiol 2010;7:148-151.
6. American College of Radiology. ACR practice parameter for communication of diagnostic imaging findings. https://www.acr.org/-/media/ACR/Files/Practice Parameters/CommunicationDiag.pdf. Revised 2014. Accessed October 2, 2019.
7. Barenfanger J, Sautter RL, Lang DL, et al. Improving patient safety by repeating (read-back) telephone reports of critical information. Am J Clin Pathol 2004;121:801-803.
8. Parl FF, O’Leary MF, Kaiser AB, et al. Implementation of a closed-loop reporting system for critical values and clinical communication in compliance with goals of The Joint Commission. Clin Chem 2010;56:417-423.
9. Beebe SA. Nurses’ perception of beeper calls. Implications for resident stress and patient care. Arch Pediatr Adolesc Med 1995;149:187-191.
10. Keane J, Pharr JR, Buttner MP, et al. Interventions to reduce loss to follow-up during all stages of the HIV care continuum in Sub-Saharan Africa: a systematic review. AIDS Behav 2017;21:1745-1754.
11. Salcedo S, McMaster KJ, Johnson SL. Disparities in treatment and service utilization among Hispanics and non-Hispanic whites with bipolar disorder. J Racial Ethn Health Disparities 2017;4:354-363.
12. Lai LL, Alfaifi A, Althemery A. Healthcare disparities in Hispanic diabetes care: a propensity score-matched study. J Immigr Minor Health 2017;19:1001-1008.