Tarangnan Community Hospital
Clinical Laboratory • Quality Management System
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Document No.: WI-QM-POST-002-A-V0 | CONTROLLED COPY Valid Only If Posted |
| Parent Policy: LAB-QM-POST-002 (Sec 5.1–5.5) | Rev: V0 | ||
| Applies to: All Medical Technologists, Duty Physicians, and Nursing Staff | Effective: MM-DD-YYYY | Supersedes: None | ||
Critical Value Panic Thresholds & 15-Minute Read-Back Wall Chart
MANDATORY IMMEDIATE ESCALATION PROTOCOL • TARGET CALL TIME: < 15 MINUTES
1. Approved Laboratory Panic Thresholds (Clinical Chemistry & Hematology)
| Examination / Analyte | Conventional | SI Units | Critical Low Limit | Critical High Limit |
|---|---|---|---|---|
| Hemoglobin (HGB) (Adult) | g/dL | g/L | < 6.5 g/dL (< 65 g/L) | > 20.0 g/dL (> 200 g/L) |
| Hematocrit (HCT) (Adult) | % | Volume fraction | < 20.0% (< 0.20 L/L) | > 60.0% (> 0.60 L/L) |
| White Blood Cell (WBC) | × 103/µL | × 109/L | < 2.0 × 103/µL (< 2.0 × 109/L) | > 30.0 × 103/µL (> 30.0 × 109/L) |
| Platelet Count (PLT) | × 103/µL | × 109/L | < 50 × 103/µL (< 50 × 109/L) | > 1,000 × 103/µL (> 1,000 × 109/L) |
| Peripheral Blood Smear | Microscopic Morphology | Initial detection of blasts or intracellular micro-organisms; acute leukemic presentation | ||
| Glucose (Adult / Pediatric) | mg/dL | mmol/L | < 45 mg/dL (< 2.5 mmol/L) | > 450 mg/dL (> 25.0 mmol/L) |
| Glucose (Neonatal) | mg/dL | mmol/L | < 30 mg/dL (< 1.7 mmol/L) | > 300 mg/dL (> 16.7 mmol/L) |
| Serum Potassium (K+) | mmol/L | mmol/L | < 2.8 mmol/L | > 6.2 mmol/L |
| Serum Sodium (Na+) | mmol/L | mmol/L | < 120 mmol/L | > 160 mmol/L |
| Serum Creatinine | mg/dL | µmol/L | None | > 5.0 mg/dL (> 442 µmol/L) new-onset |
Panic thresholds = critical results (CLSI GP47 / ISO 15189:2022).
📞 MANDATORY STANDARDIZED TELEPHONE READ-BACK SCRIPT (LAB-QM-POST-002 §5.3)
“Hello, this is [Name/ID] from the Clinical Laboratory. I have a CRITICAL LABORATORY RESULT for your patient. Please record: Patient [Full Name], Hospital ID/MRN [Number], located at [Ward/Unit]. Test [Test Name], Critical Result [Value and Units]. Please read this entire message back to me.”
→ Listen carefully to verbatim read-back. Conclude only after confirming: “Confirmed, thank you” or immediately correct discrepancies.
→ Listen carefully to verbatim read-back. Conclude only after confirming: “Confirmed, thank you” or immediately correct discrepancies.
2. Mandatory 4-Tier Escalation Hierarchy (Complete Within ≤ 15 Minutes)
TIER 1 (PRIMARY)
Attending / Requesting MD
Direct Phone Contact
Attending / Requesting MD
Direct Phone Contact
→
TIER 2 (1ST ESCALATION)
24-Hour Duty Doctor
If Attending MD Unavailable
24-Hour Duty Doctor
If Attending MD Unavailable
→
TIER 3 (2ND ESCALATION)
Nurse-in-Charge
Inpatient Ward / ER (24/7)
Nurse-in-Charge
Inpatient Ward / ER (24/7)
→
TIER 4 (ADMINISTRATIVE)
CMT / Pathologist
If All 3 Contacts Unreachable
CMT / Pathologist
If All 3 Contacts Unreachable
No voicemail/text for critical values. Callback on first occurrence only (avoid alarm fatigue).
Escalation 1 phone: ________________ | Escalation 2 phone: ________________ | Escalation 3 phone: ________________ | CMT/Pathologist phone: ________________
Escalation 1 phone: ________________ | Escalation 2 phone: ________________ | Escalation 3 phone: ________________ | CMT/Pathologist phone: ________________
1
Pre-Call Verification (§5.2)
• Tube & Request Check: Verify patient name & MRN concordance.
• Specimen Integrity: Check for micro-clots, hemolysis, lipemia.
• IQC & Repeat: Ensure run QC in control; repeat from primary tube.
• Specimen Integrity: Check for micro-clots, hemolysis, lipemia.
• IQC & Repeat: Ensure run QC in control; repeat from primary tube.
2
Mandatory Log Entry (§5.5)
Log immediately in F-QM-POST-002-A-V0:
• Exact date and notification timestamp (target ≤ 15 min).
• Patient full name, MRN, test name, critical value, units.
• Recipient full name, title, confirmed read-back, MT signature.
• Exact date and notification timestamp (target ≤ 15 min).
• Patient full name, MRN, test name, critical value, units.
• Recipient full name, title, confirmed read-back, MT signature.
| Prepared by: Chief Medical Technologist Signature/Date: _______________________ |
Reviewed by: Pathologist Signature/Date: _______________________ |
Approved by: Hospital Director Signature/Date: _______________________ |