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

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

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

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

All rights reserved.aspx. Ask a trusted family member or friend to be their advocate when they cannot "speak up" for themselves. Reference: Speak up: Help prevent errors in your care. and treatment plans. patients have become more aware and have been more cognizant of potential errors in their care. Inc.jointcommission. making sure they receive the right treatments. medical tests. patients are encouraged to: G G G G G G Pay attention to the care they receive. In recent years. .Six aims of the Institute of Medcine (IOM) to improve health care quality. Health care practitioners experience similar waiting during the course of delivering care to their patients.org/topics/speakup_brochures. Joint Commission website. Focusing upon Efficiency and Equity Inefficiency wastes resources and results in rework. Choose hospitals. Six aims of the Institute of Medcine (IOM) to improve health care quality. 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. For practitioners. 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. and other health care organizations that undergo rigorous onsite evaluation. Six aims of the Institute of Medcine (IOM) to improve health care quality. and receiving results of diagnostic procedures. clinics. surgery centers. Participate in all decisions about their health care and treatment. Available at: http://www. 2013. Click on "Topics" then "Speak Up. It can be improved by automating processes that are repetitive. Focusing upon Patient-Centered Care and Timeliness Patient-centered care focuses on ensuring that patient values guide decisions. Page 7 of 29 Copyright 2013 by MediaLab. Educate themselves about their diagnosis. to waiting for an appointment. Know their medications and why they take them. Through the efforts of the Joint Commission in its "Speak Up" campaign." Accessed November 14.

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. All rights reserved. Six aims of the Institute of Medcine (IOM) to improve health care quality. 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.such as using information systems. 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. and socioeconomic status. Inc. 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. geographic location. 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. The quality of care delivered to each individual should not vary due to personal characteristics such as gender. .

health care systems of the 21st century should strive to be safe. All rights reserved. Harm can be a false-positive or false-negative test result. IOM aims within the context of quality clinical laboratory services. Safe health care with respect to clinical laboratory services requires the reduction of opportunities for harm to the patient. Inc. Harm can also be defined as a delay in diagnosis or a patient receiving inappropriate treatment. 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).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. Page 9 of 29 Copyright 2013 by MediaLab. IOM aims within the context of quality clinical laboratory services. efficient and equitable. effective. patient-centered. timely. 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. 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. or it can be an adverse event as a result of an inappropriately performed venipuncture. .

It requires performing testing only when the sample is of adequate and of appropriate integrity--including timing of the collection. 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. 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. Increased turnaround time Inappropriately performed venipuncture or skin puncture Feedback IOM aims within the context of quality clinical laboratory services. . Inc. 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. All rights reserved. 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).Increased turnaround time Inappropriately performed venipuncture or skin puncture IOM aims within the context of quality clinical laboratory services.

All rights reserved. Inc. . Although phlebotomists' efforts focus upon individual patients and the number they interact with on a daily basis. However.IOM aims within the context of quality clinical laboratory services. Clinical Laboratory Services and Timeliness Page 11 of 29 Copyright 2013 by MediaLab. New methods need to be developed to measure numbers of patients served by clinical laboratory services. 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. the remainder of medical laboratorians examine their services with respect to numbers of samples and billable tests.

Measuring timeliness of clinical laboratory services is ingrained in medical laboratorians. 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. . 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. IOM aims within the context of quality clinical laboratory services. All rights reserved. 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. Page 12 of 29 Copyright 2013 by MediaLab. Ensuring that laboratory test results are available when clinicians need the results helps to insure that unnecessary repeat testing is not ordered nor performed. For example. Inc.

IOM aims within the context of quality clinical laboratory services.IOM aims within the context of quality clinical laboratory services. Inc. 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. . 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.

. 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. errors of omission include such things as omitting a reagent in a test. Determining how quickly laboratory tests are performed is a measure of timeliness. Page 14 of 29 Copyright 2013 by MediaLab. drawing a blood sample from the wrong patient. Errors of omission are medical errors that occur when an individual fails to act. Avoiding repeated steps in the total testing process results in efficiency. All rights reserved. Mislabeling a test specimen. 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. 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. failing to communicate a critical test result. failing to collect a timed test sample at the correct time. or treatment. care." Counting patients served instead of number of samples may improve patient-centered care. In the laboratory setting. "Using evidence to identify the best test to detect or diagnose a condition. or incubating a test at an incorrect temperature are all errors of commission. Inc.IOM aims within the context of quality clinical laboratory services.

All rights reserved. Recognizing problems (errors) that could occur in each phase of the total testing process Page 15 of 29 Copyright 2013 by MediaLab. analytic. and the postanalytic phase includes all the processes involved after test analysis. . or postanalytic phase. 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 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-.preanalytic. 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. Inc. The analytic phase consists of all the processes involved in the testing of a specimen.

.org/cgi/content/full/48/5/691#T2B.48:691-698. and are performed by both laboratory and non-laboratory personnel. 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. That is. Clin Chem.clinchem. it is still important to examine this portion of the process. 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. 2013. Rubboli F. All rights reserved. Accessed November 19. While the following list is not exhaustive. Inc. primarily listed are systematic errors.* Steps in the preanalytic phase occur both inside and outside the laboratory. Ceriotti F. Available at: http://www. Plebani M. Errors in laboratory medicine. errors that bias the measurement resulting from either instrument malfunctions or human mistakes. Following are examples of errors that may be encountered during the analytic testing activities. 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. G Errors in quality control and verification of performance specifications Page 16 of 29 Copyright 2013 by MediaLab. 2002. While random errors (those that occur independently of the operator) may be encountered during the analytic phase. illegible. However.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. The list includes both human and instrumentation errors. 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.

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. Inc. where the physician receives. and those outside the laboratory. 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. 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. this mindset is important to truly measure the safety of clinical laboratory services. All rights reserved. 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. 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.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. Providing education regarding the hows and whys of the process is respectful to the patient. or not reported in a timely manner Laboratory tests not reported or reported to the wrong health provider (For example. Page 17 of 29 Copyright 2013 by MediaLab. and acts on the laboratory results. interprets. lower case "l" interpreted as the number "1") Oral results misunderstood by receiving party. and it may prevent medical errors. However. . Similar to the preanalytic phase. 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. the postanalytic phase can be subdivided into those procedures that are within the laboratory. Improper data entry or typing mistakes causing erroneous information to be reported Critical values not reported.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. The test information and the action have an effect on the patient--either to benefit or harm the patient's health.

Page 18 of 29 Copyright 2013 by MediaLab. 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. determining the timeliness of action upon our services is an appropriate indicator to monitor. 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. . and monthly basis in each of the clinical laboratory disciplines.This will enhance the patient-centered focus of clinical laboratory services. How many people received a laboratory intervention that day. All rights reserved. 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 also important if the results are given verbally (ie. Depending upon the laboratory and hospital information system. 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. by phone) to go one step further and ask the person receiving the results to read back the patient information and test result(s). 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. consider adding the number of patients who were served on a daily. weekly. 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. this may be tracked via accession numbers or encounter numbers. One method to calculate this would require auditing the medical records of a specified number of abnormal test results. The very nature of collecting this type of data will change the clinical laboratorian's focus from specimen to patient. Inc. If clinical laboratorians are to improve the quality of health care by improving the quality of clinical laboratory services. that week. However.

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. emergency department and oncology. it is important to be selective with respect to which tests to monitor. However. All rights reserved. Consider monitoring TAT for tests performed for patients in surgery. Thus. These areas customarily use laboratory test results immediately upon receipt. . Inc.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). 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. 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. intensive care units. outliers for their respective TATs represent circumstances in which patient safety may be compromised.

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.Incorrectly handled critical test value Outcomes of patient safety errors with respect to clinical laboratory services. Outcomes of Laboratory Services Outcomes can be described as "what happened as a result of an action. All rights reserved.Incorrectly performed instrument calibration Postanalytic.Choose Choose 6 Preanalytic 6 Preanalytic Incorrecly collected sample Incorrectly performed venipuncture Feedback Preanalytic." The goal of health care is to improve the health of individuals who seek its services. wrong test ordered. Outcomes of patient safety errors with respect to clinical laboratory services.Incorrecly collected sample. Reporting of Errors Page 20 of 29 Copyright 2013 by MediaLab. 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. incorrectly performed venipuncture Analytic. . Considering this from a positive point of view. Inc. An unexpected event that has resulted in death or serious injury (physical or psychological) or an event that was averted.

or perhaps personnel are not being assessed for the competencies they need to perform the job safely. not people problems. Root Cause Analysis Example Page 21 of 29 Copyright 2013 by MediaLab. An environment of blame encourages a culture of secrecy about medical mistakes. Root Cause Analysis (continued) Root cause analysis is a process for identifying factors that cause risks. . Perhaps sufficient safeguards are not in place to prevent an error. 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. 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. The process progresses from identifying causes to identifying potential strategies that could possibly be implemented to improve the system or activity (cause and effect). Mandatory reporting laws have not overcome this secrecy. RCA focuses on systems. and common causes that were involved in the adverse event. Occurrences that may jeopardize patient safety must be investigated immediately and appropriate risk-reduction activities must be implemented. Root Cause Analysis Root cause analysis (RCA) is a structured study that determines the underlying causes of adverse events. 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. This is referred to as loss prevention. In other words. if possible. It focuses primarily on systems and processes. processes. Another reason is that a process problem is usually due to either a process flaw or a managerial error. 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. not on individual performance. One reason is so that personnel will freely report these occurrences without fear of being punished or fired.A near miss should be handled non-punitively. and they do not encourage efforts to find ways of avoiding errors. Inc. All rights reserved.

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. Root cause analysis is used primarily to examine the underlying contributors to an adverse event or condition. Some of the benefits of constructing a "fishbone diagram" are that it: G G G G Helps determine root causes using a structured approach. Encourages group participation and utilizes group knowledge. may also involve prospective attempts to predict error modes. All rights reserved. . Error analysis. using a different conceptual strategy. Outcomes of patient safety errors with respect to clinical laboratory services. FMEA differs in that its primary use is to evaluate a process prior to its implementation. Inc. In this theoretical example. which is often referred to as a "fishbone diagram" because of its appearance. the identified problem is a "near miss. 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.One of the tools that can be used when performing a root cause analysis is the cause-andeffect diagram." Two units of RBCs were taken to the Dialysis unit for tranfusion of two different patients. The blood was stopped immediately on the first patient. Indicates areas where more data should possibly be collected. Page 22 of 29 Copyright 2013 by MediaLab. One of the most commonly used prospective approaches is failure mode and effect analysis or FMEA. Failure Mode and Effect Analysis Root cause analysis (RCA) is a method of error analysis that involves retrospective investigations. 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.

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

To identify areas to monitor for improvement. Complaints from patients. 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. All rights reserved. stat turnaround times). consider focusing upon those systems or disease processes in which clinical laboratory test information has the greatest impact. it will have a more significant impact on the patient and may be more prone to error. and postanalytic). Safety. clinicians and other health care practitioners provide similar information to make improvements in clinical laboratory services. and timeliness of clinical laboratory services can be defined and measured. opportunities for process modification to improve patient safety will be identified. Outliers identified in turnaround time studies provide valuable information with respect to breakdowns in processes.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. consider those processes that are high volume. The laboratory could also monitor those circumstances in which clinical laboratory test information is used immediately (ie. analytic. use those situations as opportunities to examine how it occurred and identify methods to reduce those types of errors in process. Instead of disregarding outliers as just an aberration. or high risk. 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. 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. Select one or two processes for each phase of testing (preanalytic. Incident reports describe a variation in process and from that report. . Or. high cost.

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. All rights reserved. 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. Since 2001. opportunities for process modification to improve patient safety will be identified. Report critical results of tests and diagnostic procedures on a timely basis to the right person. the Joint Commission has published Patient Safety Goals with the intent of reducing medical/health care errors by focusing on patient safety issues.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. Inc. Reference: The Joint Commission National Patient Safety Goals. Reducing health care-associated infections has been a goal since 2004. Complaints from patients. effective January 1. 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. . Evaluation of the cost per test may be useful for identifying inefficiency. clinicians and other health care practitioners are also sources that may identify patient safety problems. Set goals for improving hand hygiene procedures. Outliers identified in turnaround time studies provide valuable information with respect to breakdowns in processes. but would not be a source of information for identifying patient safety issues. 2014. Page 25 of 29 Copyright 2013 by MediaLab. Patient identification procedures and communication of laboratory test results were included in the first list of goals in 2003. that apply to clinical laboratories are: G G G Use at least two patient identifiers when providing laboratory services. These are not new goals for the laboratory to follow. The Joint Commission National Patient Safety Goals.

jointcommission. 2013. This is of particular importance when collecting a patient sample. . Examples of acceptable patient identifiers are: G G Individual's full name An individual-specific identifier. All rights reserved. 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.http://www.org/standards_information/npsgs. it is also important to ask the patient to state his or her name. Specimens must be labeled in the presence of the patient. 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. 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. Inc.aspx Accessed November 19.

A patient's full name. birthdate. Accessed November 19. 2013.cdc. and the acceptable time between availability and reporting of critical laboratory test results. For an inpatient who has a unique hospital or medical record number. They can also be found on the CDC website at: http://www. The person who reported the result. name and birthdate could be used.html. Patient Safety Goals National Patient Safety Goal: Prevent Infection Through Hand Hygiene Proper hand hygiene reduces the risk of health care-associated infections.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. it is best to use this number also as a positive identifier. remember that at least two forms of identification are needed. All rights reserved. which reduces the number of medical errors. and the date and time of notification should be documented along with the test result. 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 procedure must define critical results of laboratory tests. 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. such as an alcohol-based hand rub. it must be monitored for compliance and timeliness. 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). Inc. These guidelines are included on this page as resources. However. For an outpatient. The person who receives the result should be asked to read back the information that is given to verify that it was heard correctly. and hospital identification number are all acceptable forms of patient identification. Following the development of the laboratory's "Communication of Critical Test Results" procedure. Page 27 of 29 Copyright 2013 by MediaLab.gov/handhygiene/Basics. by whom and to whom critical laboratory test results are communicated. the person who was notified. . 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.

Committee on Quality of Health Care in America. 2013. Clinical and Laboratory Standards Institute (CLSI). Inc. McDowell I. 191-236. To Err is Human. New York: Oxford University Presss. Therapeutic Drug Monitoring. The Centers for Disease Control and Prevention. General Health Status and Quality of Life in McDowell I. Accessed November 19. 2001. Washington. Building a Safer Health System. Newell C.gov/handhygiene/Basics. 4th ed.jointcommission. 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. Wayne. Newell C. PA: 2011. Committee on Quality of Health Care in America. Hand hygiene basics. A Guide to Rating Scales and Questionnaires. Wayne. Continual Improvement. Approved Guideline. Quality Management System: A Model for Laboratory Services. A New Health System for the 21st Century. pp. CLSI. Clinical and Laboratory Standards Institute (CLSI). PA: 2011.380-492. CT: Appleton & Lange 1995. CLSI document QMS01-A4.pdf [click to view / print] Adobe Acrobat PDF file Alcohol-based hand rub technique.cdc. Outcomes Assessment of Therapeutic Drug Monitoring: System and Patient Considerations in Schumacher GE. 2013. Available at: http://www. DC: National Academy Press. CLSI.Handwashing techniques.org/standards_information/npsgs.html. DC: National Academy Press. 3rd ed.aspx Accessed November 19. All rights reserved. pp. Schumacher GE.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. The Joint Commission National Patient Safety Goals. . Measuring Health. References References Barr JT. Crossing the Quality Chasm. 1996. Norwalk. CLSI document QMS06-A3. Approved Guideline. 2000. Washington. Page 28 of 29 Copyright 2013 by MediaLab. http://www. An analytical approach provides a foundation to examine laboratory processes with a goal of preventing medical errors.

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