Chapter 3 · Receiving and transcribing referral results

Results from referral laboratories must be received, checked for completeness, and either entered into the LIS or forwarded to the requesting clinician without alteration. If results are transcribed manually, a transcription check (second person verification or read-back) must be performed. The original report from the referral laboratory must be retained. Results must not be selectively transcribed.

Chapter 3 · Practical example

Transcribing referral results — read-back is required

When referral laboratory results are communicated verbally or transcribed manually, a read-back confirmation must be performed and documented before the result enters the patient record.

▲ The situation

A microbiologist at a referral laboratory calls with an urgent antimicrobial sensitivity result. The laboratory scientist receiving the call begins writing while listening.

Reference: ISO 15189:2022 Clause 7.7.3

✓
Good practice

The scientist writes the complete result as dictated — Staphylococcus aureus, MRSA negative, sensitive to flucloxacillin, resistant to erythromycin and clarithromycin — then reads the entire result back to the microbiologist before ending the call. The microbiologist confirms. The scientist documents: time 14:22, spoke to Dr. Petridis at GenPath, read-back performed, result entered in LIS.

✗
Poor practice

The scientist enters the result from memory after the call ends. She transcribes resistant to flucloxacillin (the opposite of what was said — she was writing when the sentence was structured and transposed the word). A patient with MSSA bacteraemia is treated with a drug to which the organism is resistant. The infection does not respond. The transcription error is discovered three days later when the patient deteriorates.

● What this means for your practice

Verbal result transcription without immediate read-back introduces a preventable patient safety risk at the highest-consequence moment. Write it down, read it back word for word, confirm, then document the confirmation. This takes 45 seconds and prevents events that can end careers and harm patients.