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Medical Error Prevention: Patient Safety
Authors: Catherine Otto, PhD, CLS(NCA); Garland Pendergraph, PhD, JD, SM(ASCP) Reviewer: Barbara Cebulski, MS, MLS(ASCP)CM

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Course Instructions Please proceed through the course by clicking on the blue arrows or text links. Use the table of contents to monitor your progress. and you may later continue where you left off even if you use a different computer. which are not graded or recorded. Page 3 of 29 Copyright 2013 by MediaLab. . Your progress will be saved automatically as you proceed through the course. You may encounter practice questions within the course. Inc. All rights reserved.

Medical Errors: 2.00 hour(s) Course Number: 578-012-11 Florida Board of Clinical Laboratory Science CE .E. Inc.00 hour(s) Page 4 of 29 Copyright 2013 by MediaLab. Contact Hours: 2. .Course Info This course carries the following continuing education credits: G G P.A. All rights reserved.C.

Although there has been a greater focus upon reducing errors in hospital settings.Six aims of the Institute of Medcine (IOM) to improve health care quality. at the worst. medical care delivered in outpatient and other non-hospital settings are not immune from error prone systems. reported that between 44. medication errors. add new technology. Using unnecessary resources to address these errors reduces opportunities to provide care for uninsured individuals. All rights reserved. serious adverse events. Six aims of the Institute of Medcine (IOM) to improve health care quality. nosocomial infections. and other failures in the delivery of care. Health care systems should be: G G G G G G Safe Effective Patient-centered Timely Efficient Equitable Six aims of the Institute of Medcine (IOM) to improve health care quality. For patients who do not die.000 individuals died while hospitalized in the United States in 1997 due to medical error. continue to occur in health care organizations throughout the country. However. but the IOM's messages and recommendations continue to be opportune. Inc. however. (IOM). a 2000 publication from the Institute of Medicine. Six Institute of Medicine Aims In response to the publication of To Err is Human.000 and 98. at the minimum they experience repetitive testing and procedures and extended hospital stay. the IOM published strategies in Crossing the Quality Chasm to reduce errors in health care and improve its quality. including wrong site surgeries. These expectations are routinely met by the health care community. . Everyone expects to give and receive effective medical care. Deaths occurred due to medication errors. and nosocomial infections. The IOM identified six aims for health care systems of the 21st century. These increase overall costs to health insurance companies and individuals. yet experience a medical error during their hospital stay. It has been several years since the IOM published To Err is Human. or support new programs. they may leave a patient with a comorbidity or disability. State of Health Care Quality Most medical interventions produce positive outcomes. To Err is Human: Building a Safer Health System. Health care practitioners and patients may be more aware of these recommendations today. Six Institute of Medicine Aims (continued) Page 5 of 29 Copyright 2013 by MediaLab.

However. Heath care that is equitable "does not vary in quality because of attributes such as gender. ideas. is only one aspect of the broad term that "patient safety" encompasses. followed by receiving interventions needed to treat those conditions. Page 6 of 29 Copyright 2013 by MediaLab. Improving Effectiveness Problems in health care quality have focused upon medical errors--harm to patients that resulted due to experiences with the health care system. Health care that is efficient avoids waste. Effective health care provides services based upon scientific knowledge to those who would benefit from that care and refrains from providing care to those who are not likely to benefit. 2. Scientific evidence is critical to identify appropriate tests and treatments so that overutilization. . All rights reserved. yet appropriate and adequate tests are performed in order to diagnose and treat conditions in a timely manner. Washington. 3."* Patients should not be harmed while receiving health care from events such as nosocomial infections. underutilization and misutilization of health care processes is limited. Health care that is effective is one that does not perform more tests than necessary to diagnose and treat patients' conditions. A New Health System for the 21st Century. Because the IOM has defined health care quality as "The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge. or other iatrogenic sequelae resulting from interaction with any aspect of the health care system. not those of the health care provider. safety--doing no harm. ethnicity. 6. Health care that is safe "avoids injuries to patients from the care that is intended to help them." its six aims include more than avoiding or reducing harm in the health care delivery process." Patients should receive care at the time when it would be most helpful in identifying the cause of their condition. geographic location and socioeconomic status. This includes waste of equipment. and values.1. Patient-centered health care is care that is delivered in a manner that is "respectful of and responsive to individual's preferences. 5." *Reference: Committee on Quality of Health Care in America. 2001. needs. Health care that is effective avoids underuse and overuse of services." The principle of this aim is that it is patients' values that guide all clinical decisions. energy and time. supplies. missed diagnosis. Six aims of the Institute of Medcine (IOM) to improve health care quality. Health care that is timely "reduces waits and harmful delays for those who receive and those who provide care. 4. for both patients and health care practitioners. DC: National Academy Press. Inc. Crossing the Quality Chasm.

Know their medications and why they take them. Educate themselves about their diagnosis. patient-centered care encompasses these actions: G G G G G Coordinating the services patients receive Communicating in a manner that patients understand Alleviating anxiety Reducing patients' pain Involving patients' family members in decision making if they have the role of caregivers Timeliness is critical throughout the entire health care delivery process--beginning with time waiting on hold to make an appointment or to speak to a clinician. clinics. All rights reserved. to waiting for an appointment. Participate in all decisions about their health care and treatment. Preventing Medical Errors Through Patient Involvement Patients and their families should be encouraged to become active participants in their health care and "speak up" when they have questions and concerns. Inc. patients are encouraged to: G G G G G G Pay attention to the care they receive.aspx. Through the efforts of the Joint Commission in its "Speak Up" campaign. Six aims of the Institute of Medcine (IOM) to improve health care quality. In recent years. 2013.org/topics/speakup_brochures. making sure they receive the right treatments. Page 7 of 29 Copyright 2013 by MediaLab. medical tests. Ask a trusted family member or friend to be their advocate when they cannot "speak up" for themselves.Six aims of the Institute of Medcine (IOM) to improve health care quality. Focusing upon Efficiency and Equity Inefficiency wastes resources and results in rework. Available at: http://www. and other health care organizations that undergo rigorous onsite evaluation. Health care practitioners experience similar waiting during the course of delivering care to their patients. Six aims of the Institute of Medcine (IOM) to improve health care quality. It can be improved by automating processes that are repetitive. . and receiving results of diagnostic procedures." Accessed November 14. patients have become more aware and have been more cognizant of potential errors in their care.jointcommission. Joint Commission website. surgery centers. Focusing upon Patient-Centered Care and Timeliness Patient-centered care focuses on ensuring that patient values guide decisions. Click on "Topics" then "Speak Up. For practitioners. Choose hospitals. and treatment plans. Reference: Speak up: Help prevent errors in your care.

All rights reserved. Please select all correct answers c Centralized d e f g c Efficient d e f g c Effective d e f g c Profitable d e f g c Timely d e f g c Patient-centered d e f g c Physician-centered d e f g Six aims of the Institute of Medcine (IOM) to improve health care quality. The quality of care delivered to each individual should not vary due to personal characteristics such as gender. Ungraded Practice Question Which of the following are included in the Institute of Medicine (IOM) aims to improve the quality of health care in the United States? Health care systems should be: More than one answer is correct. or it can be improved by limiting the amount of rework that is performed by addressing each situation as it arises. . Six aims of the Institute of Medcine (IOM) to improve health care quality. and socioeconomic status. Inc. The role of equity in the health care delivery system is to improve the health of the entire population and to provide that care without discrimination.such as using information systems. Ungraded Practice Question Which of the following are included in the Institute of Medicine (IOM) aims to improve the quality of health care in the United States? Health care systems should be: More than one answer is correct. Please select all correct answers c Centralized d e f g c Efficient d e f g c Effective d e f g c Profitable d e f g Page 8 of 29 Copyright 2013 by MediaLab. geographic location.

. IOM aims within the context of quality clinical laboratory services. IOM aims within the context of quality clinical laboratory services. Clinical Laboratory Services and Safety The key to identifying whether clinical laboratory services provide safe health care is to determine the harm that ensues as a result of inappropriately delivered clinical laboratory services. health care systems of the 21st century should strive to be safe. Inc. efficient and equitable. All rights reserved. Harm can be a false-positive or false-negative test result. or it can be an adverse event as a result of an inappropriately performed venipuncture. How might patient harm result from each of these problems related to clinical laboratory services? Consider your answer and then click on the defined problem to reveal the potentially harmful result(s) of the action or condition. Page 9 of 29 Copyright 2013 by MediaLab. timely. patient-centered. Harm can also be defined as a delay in diagnosis or a patient receiving inappropriate treatment.c Timely d e f g c Patient-centered d e f g c Physician-centered d e f g Feedback According to the IOM. Safe health care with respect to clinical laboratory services requires the reduction of opportunities for harm to the patient. False-positive (laboratory test result is reported as positive when it is really negative) or false-negative test result (laboratory test result is reported as negative when it is really positive). effective.

All rights reserved. It requires performing testing only when the sample is of adequate and of appropriate integrity--including timing of the collection. . It requires using evidence (scientific knowledge) to establish how often a test should be performed during a hospitalization and removing antiquated and ineffective testing methodologies from the testing menu. Increased turnaround time Inappropriately performed venipuncture or skin puncture Feedback IOM aims within the context of quality clinical laboratory services. Inc.Increased turnaround time Inappropriately performed venipuncture or skin puncture IOM aims within the context of quality clinical laboratory services. False-positive (laboratory test result is reported as positive when it is really negative) or false-negative test result (laboratory test result is reported as negative when it is really positive). How might patient harm result from each of these problems related to clinical laboratory services? Consider your answer and then click on the defined problem to reveal the potentially harmful result(s) of the action or condition. Page 10 of 29 Copyright 2013 by MediaLab. Clinical Laboratory Services and Effectiveness Clinical laboratory services that are effective provide testing that benefits all those who receive it.

All rights reserved. Clinical Laboratory Services and Timeliness Page 11 of 29 Copyright 2013 by MediaLab. IOM aims within the context of quality clinical laboratory services. Clinical Laboratory Services and Patient-Centered Care Associating clinical laboratory services with patient-centered care may seem difficult as laboratory workers usually do not interact with patients. the first step to improving this aspect of health care quality is to shift the focus from specimens to patients. Although phlebotomists' efforts focus upon individual patients and the number they interact with on a daily basis.IOM aims within the context of quality clinical laboratory services. New methods need to be developed to measure numbers of patients served by clinical laboratory services. However. the remainder of medical laboratorians examine their services with respect to numbers of samples and billable tests. . Inc.

Page 12 of 29 Copyright 2013 by MediaLab. For example. a more accurate description of timeliness begins with the time from test order entry and also identifies how long it routinely takes for action to be taken after test results are sent to a clinician. Inc. . Timeliness needs to be expanded to encompass more than the portion of the total testing process that occurs within the walls of the clinical laboratory. IOM aims within the context of quality clinical laboratory services. All rights reserved.Measuring timeliness of clinical laboratory services is ingrained in medical laboratorians. Ensuring that laboratory test results are available when clinicians need the results helps to insure that unnecessary repeat testing is not ordered nor performed. Clinical Laboratory Services and Efficiency Efficiency with respect to clinical laboratory services is best described as avoiding repeated steps in the total testing process and decreasing rework.

Inc. Clinical Laboratory Services and Equity Equity in providing clinical laboratory services is best described as ensuring that services are not preferentially provided to one group of individuals over others. . All rights reserved. Ungraded Practice Question Which of the following best defines "effective clinical laboratory services?" Please select the single best answer j Counting patients served instead of number of samples k l m n j Using evidence to identify the best test to detect or diagnose a condition k l m n j Determining how quickly laboratory tests are performed k l m n j Avoiding repeated steps in the total testing process k l m n Page 13 of 29 Copyright 2013 by MediaLab.IOM aims within the context of quality clinical laboratory services. IOM aims within the context of quality clinical laboratory services.

drawing a blood sample from the wrong patient. Errors of omission are medical errors that occur when an individual fails to act. care. Avoiding repeated steps in the total testing process results in efficiency. All rights reserved. Mislabeling a test specimen. .IOM aims within the context of quality clinical laboratory services. or incubating a test at an incorrect temperature are all errors of commission. Categories of medical errors include: G G G Failures of planned actions Mistakes of execution Use of wrong plans to achieve outcomes There are two types of medical errors: Errors of commission Errors of omission Errors of commission are medical errors involving wrong actions. or treatment." Counting patients served instead of number of samples may improve patient-centered care. Page 14 of 29 Copyright 2013 by MediaLab. failing to collect a timed test sample at the correct time. failing to communicate a critical test result. "Using evidence to identify the best test to detect or diagnose a condition. Ungraded Practice Question Which of the following best defines "effective clinical laboratory services?" Please select the single best answer j Counting patients served instead of number of samples k l m n j Using evidence to identify the best test to detect or diagnose a condition k l m n j Determining how quickly laboratory tests are performed k l m n j Avoiding repeated steps in the total testing process k l m n Feedback Effective clinical laboratory services can be defined as. Determining how quickly laboratory tests are performed is a measure of timeliness. Recognizing problems (errors) that could occur in each phase of the total testing process Medical Errors Medical errors are mistakes medical professionals make in patient testing. In the laboratory setting. Inc. errors of omission include such things as omitting a reagent in a test.

The preanalytic phase of testing includes all processes prior to the actual testing of a specimen. Recognizing problems (errors) that could occur in each phase of the total testing process Page 15 of 29 Copyright 2013 by MediaLab. analytic.Recognizing problems (errors) that could occur in each phase of the total testing process Factors that Contribute to Medical Errors Multi-tasking Automatic actions (automaticity) Suboptimal work environment Recognizing problems (errors) that could occur in each phase of the total testing process Factors that Contribute to Medical Errors Multi-tasking Automatic actions (automaticity) Suboptimal work environment Feedback Recognizing problems (errors) that could occur in each phase of the total testing process Total Testing Process Medical errors are possible at any phase of patient care-. Monitoring processes in all three phases of testing are key to ensuring patient safety and reducing the possibility of medical errors related to laboratory testing.preanalytic. The analytic phase consists of all the processes involved in the testing of a specimen. Inc. . or postanalytic phase. All rights reserved. and the postanalytic phase includes all the processes involved after test analysis.

While the following list is not exhaustive. errors that bias the measurement resulting from either instrument malfunctions or human mistakes. Accessed November 19. and are performed by both laboratory and non-laboratory personnel.Safe Preanalytic Component of Total Testing Process A study that was published in 2002 concluded that the majority of laboratory errors occur in the preanalytic phase of testing.clinchem. Recognizing problems (errors) that could occur in each phase of the total testing process Safe Analytic Component of Total Testing Process Automation has improved the accuracy and improved the safety of the analytic component of the total testing process.48:691-698. specimen that should be placed on ice immediately after collection is transported at ambient temperature) Shipment of specimen H Shipped at ambient temperature when it should have been shipped frozen H Delay in shipment Order entry H Incorrect data entered during manual entry of a test requisition *Reference: Bonini P. Ceriotti F. illegible. The list includes both human and instrumentation errors. . Rubboli F.org/cgi/content/full/48/5/691#T2B. Errors in laboratory medicine. While random errors (those that occur independently of the operator) may be encountered during the analytic phase. That is. some of the most common sources of error in the preanalytic phase include: G G G G G G G Patient preparation H Patient not told to be fasting H Improper or no instruction to patient on proper collection of specimen such as clean catch urine Patient injured during phlebotomy H Development of hematoma H Nerve or tissue damage caused by improper technique or wrong-site venipuncture Requisition errors H Patient information missing. or on wrong patient H Wrong tests ordered Patient identification H Patient incorrectly identified H Specimen not labeled or incorrectly labeled Specimen integrity H Not enough specimen for testing H Visible hemolysis H Inadequate cleansing of venipuncture site resulting in contamination during blood culture collection H Specimen centrifuged too long or not long enough H Specimen placed in improper preservative H Specimen transported at the wrong temperature (eg.* Steps in the preanalytic phase occur both inside and outside the laboratory. However. Plebani M. Available at: http://www. G Errors in quality control and verification of performance specifications Page 16 of 29 Copyright 2013 by MediaLab. primarily listed are systematic errors. it is still important to examine this portion of the process. Clin Chem. All rights reserved. 2002. 2013. Inc. Following are examples of errors that may be encountered during the analytic testing activities.

lower case "l" interpreted as the number "1") Oral results misunderstood by receiving party. interprets. Recognizing problems (errors) that could occur in each phase of the total testing process Patient-Centered Preanalytic Component of Total Testing Process Clinical laboratory test information is only as good as the sample collected. Page 17 of 29 Copyright 2013 by MediaLab. poor communication to a patient's physician of the results of laboratory tests that are pending at the time of a patient's discharge) Lack of timeliness of reporting laboratory results (slow turnaround time) Misinterpretation of an alphabetic flag in the result field (eg. . and acts on the laboratory results. Inc.G G G G G G G Instrument malfunctions Calibration errors causing a direction of bias in results Manual pipetting errors Reagent errors Specimen interference (eg. where the physician receives. Similar to the preanalytic phase. However. Examples of errors that could occur in the postanalytic phase include: G G G G G G G G G G Laboratory results not verified before being reported. it will improve sample integrity. and those outside the laboratory. or not reported in a timely manner Laboratory tests not reported or reported to the wrong health provider (For example. the postanalytic phase can be subdivided into those procedures that are within the laboratory. and it may prevent medical errors. significant attention has been focused on errors made during the postanalytic phase of laboratory testing and the impact errors made during this phase have on laboratory-related patient outcomes. this mindset is important to truly measure the safety of clinical laboratory services. Providing education regarding the hows and whys of the process is respectful to the patient.no "read back" requested to confirm that data was correctly received Abnormal test not recognized by the clinician Failure of clinician to order appropriate follow-up testing Failure of clinician to communicate test results and next steps to patient and family In the postanalytic phase. All rights reserved. The test information and the action have an effect on the patient--either to benefit or harm the patient's health. Improper data entry or typing mistakes causing erroneous information to be reported Critical values not reported. the test result becomes information that the clinician must act upon. Tracking what occurs after laboratory test results are sent to clinicians is a new concept for clinical laboratorians. lipemia or hemolysis) Calculation errors Inadequate staffing which may precipitate errors caused by fatigue Recognizing problems (errors) that could occur in each phase of the total testing process Safe Postanalytic Component of Total Testing Process Recently. Allow time: G G G For patients to ask questions To share information that is important to the sample collection process To describe post-venipuncture self-care information.

All rights reserved. Page 18 of 29 Copyright 2013 by MediaLab. If clinical laboratorians are to improve the quality of health care by improving the quality of clinical laboratory services. . determining the timeliness of action upon our services is an appropriate indicator to monitor. The very nature of collecting this type of data will change the clinical laboratorian's focus from specimen to patient. or that month? Collecting other data such as the number and the subsequent rate of abnormal tests and critical test results will also provide valuable prevalence information for the population of patients served by the laboratory. we do not have a standard definition of how to measure turnaround time. How many people received a laboratory intervention that day. One method to calculate this would require auditing the medical records of a specified number of abnormal test results. This has been valuable because tests have different levels of importance with respect to timeliness given patient's clinical situation or nature of the specimen. this may be tracked via accession numbers or encounter numbers. and monthly basis in each of the clinical laboratory disciplines. Recognizing problems (errors) that could occur in each phase of the total testing process Timely: Reduce Wait Times and Harmful Delays Clinical laboratorians have been measuring and reporting turnaround times for decades. that week. by phone) to go one step further and ask the person receiving the results to read back the patient information and test result(s). weekly.This will enhance the patient-centered focus of clinical laboratory services. consider adding the number of patients who were served on a daily. Inc. It is also important if the results are given verbally (ie. However. Recognizing problems (errors) that could occur in each phase of the total testing process Patient-Centered Postanalytic Component of Total Testing Process Immediately communicating critical test results to the clinical person who is in charge of the patient's care is a postanalytic patient-centered component of the total testing process. Is turnaround time defined as the time from when the clinician orders the laboratory test to the time when the clinician takes action on the test results? Or is it the time from when the sample is collected to the time the laboratory test result is reported to the clinician? Or is it something else? Defining turnaround time as the time when the clinician orders the laboratory test to the time when the clinician takes action on the test results measures the total testing process. Depending upon the laboratory and hospital information system. Recognizing problems (errors) that could occur in each phase of the total testing process Patient-Centered Analytic Component of Total Testing Process In addition to tracking the number of tests performed or the billable tests performed.

it is important to be selective with respect to which tests to monitor.Recognizing problems (errors) that could occur in each phase of the total testing process Timely: Reduce Waits and Harmful Delays (continued) There is extraordinary value in measuring turnaround times (TAT). outliers for their respective TATs represent circumstances in which patient safety may be compromised. Consider monitoring TAT for tests performed for patients in surgery. Select the correct match for each item from the drop-down box Choose Choose Choose 6 Postanalytic Incorrectly handled critical test value 6 Preanalytic 6 Analytic Wrong test ordered Incorrectly performed instrument calibration Page 19 of 29 Copyright 2013 by MediaLab. emergency department and oncology. Select the correct match for each item from the drop-down box Choose Choose Choose Choose Choose 6 Incorrectly handled critical test value 6 Wrong test ordered 6 Incorrectly performed instrument calibration 6 Incorrecly collected sample 6 Incorrectly performed venipuncture Recognizing problems (errors) that could occur in each phase of the total testing process Ungraded Practice Question Identify the phase of the total testing process in which each of these errors occurs. Thus. . intensive care units. These areas customarily use laboratory test results immediately upon receipt. Inc. All rights reserved. Recognizing problems (errors) that could occur in each phase of the total testing process Ungraded Practice Question Identify the phase of the total testing process in which each of these errors occurs. However.

Inc. An unexpected event that has resulted in death or serious injury (physical or psychological) or an event that was averted. but may have resulted in death or serious injury (often referred to as a "near miss") must be investigated by performing a root cause analysis.Incorrecly collected sample. outcomes of laboratory services include: G G G G G G G G Living Getting well Improving health and function Being cured Receiving a proper diagnosis Going into remission Receiving a treatment or medication adjustment Being discharged from the hospital Negative patient outcomes of laboratory services include: G G G G G Inappropriate medical treatment Inappropriate medication adjustment Incorrect diagnosis Delayed diagnosis Delayed treatment All of these negative outcomes require investigation. Reporting of Errors Page 20 of 29 Copyright 2013 by MediaLab. Outcomes of Laboratory Services Outcomes can be described as "what happened as a result of an action. Considering this from a positive point of view.Incorrectly handled critical test value Outcomes of patient safety errors with respect to clinical laboratory services." The goal of health care is to improve the health of individuals who seek its services. All rights reserved.Incorrectly performed instrument calibration Postanalytic. incorrectly performed venipuncture Analytic.Choose Choose 6 Preanalytic 6 Preanalytic Incorrecly collected sample Incorrectly performed venipuncture Feedback Preanalytic. Outcomes of patient safety errors with respect to clinical laboratory services. . wrong test ordered.

All rights reserved. An environment of blame encourages a culture of secrecy about medical mistakes. or perhaps personnel are not being assessed for the competencies they need to perform the job safely. Inc. RCA focuses on systems. and they do not encourage efforts to find ways of avoiding errors.A near miss should be handled non-punitively. Occurrences that may jeopardize patient safety must be investigated immediately and appropriate risk-reduction activities must be implemented. Root Cause Analysis Example Page 21 of 29 Copyright 2013 by MediaLab. Mandatory reporting laws have not overcome this secrecy. The process progresses from identifying causes to identifying potential strategies that could possibly be implemented to improve the system or activity (cause and effect). Root Cause Analysis (continued) Root cause analysis is a process for identifying factors that cause risks. It focuses primarily on systems and processes. Another reason is that a process problem is usually due to either a process flaw or a managerial error. It then determines ways to prevent recurrence by identifying potential improvements in systems and processes that should decrease the likelihood of repeating the event. Outcomes of patient safety errors with respect to clinical laboratory services. . Perhaps sufficient safeguards are not in place to prevent an error. not on individual performance. not people problems. Some examples of risk control treatments in loss prevention might include: G G G Staff education Procedure revisions Policy review Outcomes of patient safety errors with respect to clinical laboratory services. and common causes that were involved in the adverse event. This is referred to as loss prevention. One reason is so that personnel will freely report these occurrences without fear of being punished or fired. Root Cause Analysis Root cause analysis (RCA) is a structured study that determines the underlying causes of adverse events. if possible. processes. Outcomes of patient safety errors with respect to clinical laboratory services. Error reduction requires a commitment from the community to recognize and acknowledge that medical errors most often indicate systems problems. after determining what caused the risk in the first place the next step is to determine what can be done to stop the risk from happening in the future. In other words.

One of the most commonly used prospective approaches is failure mode and effect analysis or FMEA. Some of the benefits of constructing a "fishbone diagram" are that it: G G G G Helps determine root causes using a structured approach. may also involve prospective attempts to predict error modes. Inc. Failure Mode and Effect Analysis Root cause analysis (RCA) is a method of error analysis that involves retrospective investigations. The blood was stopped immediately on the first patient. which is often referred to as a "fishbone diagram" because of its appearance. Root cause analysis is used primarily to examine the underlying contributors to an adverse event or condition. using a different conceptual strategy. Indicates possible variations in a process. Cause-and-Effect (Fishbone) Diagram Example This type of diagram graphically helps identify and organize known or possible causes for a specific problem or area of concern." Two units of RBCs were taken to the Dialysis unit for tranfusion of two different patients. FMEA differs in that its primary use is to evaluate a process prior to its implementation.One of the tools that can be used when performing a root cause analysis is the cause-andeffect diagram. Indicates areas where more data should possibly be collected. In this theoretical example. Its purpose is to identify ways in which a process might possibly fail with the goal being to eliminate or reduce the likelihood of such a failure. Page 22 of 29 Copyright 2013 by MediaLab. Encourages group participation and utilizes group knowledge. . Error analysis. Outcomes of patient safety errors with respect to clinical laboratory services. The first unit was hung by one clinical person and started just as another clinical person noticed that the unit that he/she picked up for transfusing another patient had the wrong identifying information. All rights reserved. the identified problem is a "near miss.

document the investigation. Inc. Page 23 of 29 Copyright 2013 by MediaLab. document investigation. and implement appropriate risk-reduction processes. Another reason is because a problem is usually due to either a process flaw or a managerial error. A near miss may be an isolated incident. but it is important to perform a root cause analysis to understand what may have contributed to the error and what steps should be taken to prevent it from happening again. but may have resulted in death or serious injury). k l m n j Be thankful that the patient was not seriously injured and hope it doesn't happen again. The error was caught in time before serious injury occurred. or perhaps personnel are not being assessed for the competencies they need to perform the job safely. . but may have resulted in death or serious injury). The error was caught in time before serious injury occurred. document investigation. All rights reserved. k l m n j Fire the person who was responsible.Outcomes of patient safety errors with respect to clinical laboratory services. Which of the following is an appropriate response to improve the process involved and patient safety? Please select the single best answer j Perform a root cause analysis. and implement appropriate risk-reduction processes. Perhaps sufficient safeguards are not in place to prevent an error. k l m n Outcomes of patient safety errors with respect to clinical laboratory services. Which of the following is an appropriate response to improve the process involved and patient safety? Please select the single best answer j Perform a root cause analysis. One reason is so that personnel will freely report these occurrences without fear of being punished or fired. and implement appropriate risk-reduction activities. perhaps with a more dire outcome. Ungraded Practice Question A patient event occurs that results in a "near miss" (an event that was averted. k l m n j Fire the person who was responsible. Ungraded Practice Question A patient event occurs that results in a "near miss" (an event that was averted. k l m n Feedback The appropriate response to a near miss is to perform a root cause analysis. A near miss should be handled non-punitively. k l m n j Be thankful that the patient was not seriously injured and hope it doesn't happen again. if possible.

Outliers identified in turnaround time studies provide valuable information with respect to breakdowns in processes. clinicians and other health care practitioners provide similar information to make improvements in clinical laboratory services. Incident reports describe a variation in process and from that report. . consider focusing upon those systems or disease processes in which clinical laboratory test information has the greatest impact. Sources of data to identify errors and patient outcomes Data sources to identify errors Variation in the total testing process is a valuable place to examine opportunities to improve clinical laboratory services. The laboratory could also monitor those circumstances in which clinical laboratory test information is used immediately (ie. Or. To identify areas to monitor for improvement. and postanalytic). Instead of disregarding outliers as just an aberration. Sources of data to identify errors and patient outcomes Ungraded Practice Question Which of these sources may be useful for identifying patient safety problems? More than one answer is correct. analytic. Safety. and timeliness of clinical laboratory services can be defined and measured. or high risk. opportunities for process modification to improve patient safety will be identified. All rights reserved. high cost. consider those processes that are high volume. it will have a more significant impact on the patient and may be more prone to error. Please select all correct answers c Cost per test d e f g c Complaints from patients d e f g c Outliers or variation in any monitored process d e f g c Incident reports d e f g Page 24 of 29 Copyright 2013 by MediaLab. Inc. efficiency. Select one or two processes for each phase of testing (preanalytic. Complaints from patients. stat turnaround times). use those situations as opportunities to examine how it occurred and identify methods to reduce those types of errors in process.Sources of data to identify errors and patient outcomes Monitoring Laboratory Processes to Prevent Medical Errors Monitoring laboratory processes is a proactive approach to prevention of medical errors and assurance of patient safety. When information must be used immediately or without other data.

. 2014. These are not new goals for the laboratory to follow. effective January 1. the Joint Commission has published Patient Safety Goals with the intent of reducing medical/health care errors by focusing on patient safety issues. Reducing health care-associated infections has been a goal since 2004. Set goals for improving hand hygiene procedures. opportunities for process modification to improve patient safety will be identified. clinicians and other health care practitioners are also sources that may identify patient safety problems. Inc. Please select all correct answers c Cost per test d e f g c Complaints from patients d e f g c Outliers or variation in any monitored process d e f g c Incident reports d e f g Feedback Incident reports describe a variation in process and from that report. Patient Safety Goals The Joint Commission National Patient Safety Goals 2014 for Clinical Laboratories The Joint Commission is an independent agency that accredits health care organizations and programs. Page 25 of 29 Copyright 2013 by MediaLab. Since 2001. Outliers identified in turnaround time studies provide valuable information with respect to breakdowns in processes. Comply with either the current Centers for Disease Control and Prevention (CDC) hand hygiene guidelines or the current World Health Organization (WHO) hand hygiene guidelines. Report critical results of tests and diagnostic procedures on a timely basis to the right person. but would not be a source of information for identifying patient safety issues. Evaluation of the cost per test may be useful for identifying inefficiency. that apply to clinical laboratories are: G G G Use at least two patient identifiers when providing laboratory services. Complaints from patients. Reference: The Joint Commission National Patient Safety Goals.Sources of data to identify errors and patient outcomes Ungraded Practice Question Which of these sources may be useful for identifying patient safety problems? More than one answer is correct. Patient identification procedures and communication of laboratory test results were included in the first list of goals in 2003. The Joint Commission National Patient Safety Goals. All rights reserved.

Inc. Examples of acceptable patient identifiers are: G G Individual's full name An individual-specific identifier. Patient Safety Goals National Patient Safety Goal: Identify Patients Correctly Two patient identifiers should be used at any stage of the laboratory total testing process.http://www. All rights reserved.org/standards_information/npsgs. This is of particular importance when collecting a patient sample.jointcommission. it is also important to ask the patient to state his or her name. Specimens must be labeled in the presence of the patient. such as H birth date H hospital number H medical record number H other assigned unique identification number If a patient is able to respond. 2013. . Patient Safety Goals Ungraded Practice Question Which of the following is NOT an acceptable patient identifier to use prior to performing venipuncture procedures? Please select the single best answer j Patient's complete name k l m n j Birth date k l m n j Hospital identification number k l m n j Patient's room number k l m n Patient Safety Goals Ungraded Practice Question Which of the following is NOT an acceptable patient identifier to use prior to performing venipuncture procedures? Page 26 of 29 Copyright 2013 by MediaLab.aspx Accessed November 19.

and hospital identification number are all acceptable forms of patient identification. Accessed November 19. name and birthdate could be used. 2013. For an inpatient who has a unique hospital or medical record number.cdc. The person who reported the result. Critical laboratory test results that are given over the phone must only be given to a clinical person (person in charge of the patient's care). They can also be found on the CDC website at: http://www. remember that at least two forms of identification are needed.html.gov/handhygiene/Basics. All rights reserved. However. Inc. These guidelines are included on this page as resources. The procedure must define critical results of laboratory tests. it is best to use this number also as a positive identifier. and the date and time of notification should be documented along with the test result. . A patient's full name. by whom and to whom critical laboratory test results are communicated. Following the development of the laboratory's "Communication of Critical Test Results" procedure. which reduces the number of medical errors. The Centers for Disease Control and Prevention (CDC) has posted on its website guidelines from the World Health Organization (WHO) for proper hand hygiene techniques. The person who receives the result should be asked to read back the information that is given to verify that it was heard correctly. Patient Safety Goals National Patient Safety Goal: Improve Staff Communication Effective communication of critical results of laboratory tests to a licensed caregiver in a timely manner is required for this National Patient Safety Goal. Patient Safety Goals National Patient Safety Goal: Prevent Infection Through Hand Hygiene Proper hand hygiene reduces the risk of health care-associated infections. it must be monitored for compliance and timeliness. and the acceptable time between availability and reporting of critical laboratory test results. birthdate.Please select the single best answer j Patient's complete name k l m n j Birth date k l m n j Hospital identification number k l m n j Patient's room number k l m n Feedback Patient's location in the hospital is not a unique identifier. Hand hygiene is a term that means cleansing of the hands by either washing with soap and water or by applying an antiseptic agent to the hands. the person who was notified. For an outpatient. such as an alcohol-based hand rub. Page 27 of 29 Copyright 2013 by MediaLab.

Newell C. CLSI.pdf [click to view / print] Adobe Acrobat PDF file Conclusion Measurement and the Improvement of Clinical Laboratory Services Although clinical laboratory services have been measuring the quality of its services with proficiency testing and accreditation programs for decades. Therapeutic Drug Monitoring. CLSI document QMS01-A4. 2013. CT: Appleton & Lange 1995. Measuring Health. CLSI. 1996. Inc. Wayne. Continual Improvement. Building a Safer Health System.aspx Accessed November 19. References References Barr JT. 4th ed. . Crossing the Quality Chasm.org/standards_information/npsgs. Accessed November 19. pp. pp. http://www. McDowell I. New York: Oxford University Presss. Hand hygiene basics. 2001. The Centers for Disease Control and Prevention. All rights reserved. 191-236. Approved Guideline. Approved Guideline. 2000. Wayne.jointcommission. Available at: http://www. A Guide to Rating Scales and Questionnaires.Handwashing techniques. Washington. 3rd ed. CLSI document QMS06-A3. Quality Management System: A Model for Laboratory Services. 2013. DC: National Academy Press. there are always areas for improvement that can be realized by examining the total testing process with respect to errors and outcomes and improving effectiveness and patient-centeredness of our services.gov/handhygiene/Basics. Outcomes Assessment of Therapeutic Drug Monitoring: System and Patient Considerations in Schumacher GE. A New Health System for the 21st Century. Committee on Quality of Health Care in America. DC: National Academy Press. Page 28 of 29 Copyright 2013 by MediaLab. Clinical and Laboratory Standards Institute (CLSI). Schumacher GE. Newell C.380-492. Washington.html. Norwalk. General Health Status and Quality of Life in McDowell I. The Joint Commission National Patient Safety Goals. To Err is Human. Clinical and Laboratory Standards Institute (CLSI). An analytical approach provides a foundation to examine laboratory processes with a goal of preventing medical errors. PA: 2011.pdf [click to view / print] Adobe Acrobat PDF file Alcohol-based hand rub technique.cdc. Committee on Quality of Health Care in America. PA: 2011.

All rights reserved. . Inc.Page 29 of 29 Copyright 2013 by MediaLab.