Root Cause Analysis: Sharp Rees-Stealy Labs
Ashley Knepler, BS, MS-HCI Student
Faculty advisor: Dorothy O’Hagan, MNLM, RHIA,CCS
BACKGROUND
• Sharp Rees-Stealy is one of the
leading healthcare organizations
in San Diego
• Has 21 medical centers
throughout San Diego
• When lab specimens are taken
at the clinics, they are
transported to two labs: Copley
or Pacific Rim
• Influx of lab specimens being
sent to the incorrect labs
PURPOSE
• To identify the failure points
within the established process
and suggest process
improvements
• Some lab specimens are time
sensitive, for example, breast
biopsy has 72 hours to be
processed
• Sharp’s mission is providing the
best quality of care for the
patient, this error can disrupt a
patient’s care and put it at risk
PROJECT APPROACH
• Role in project: Assist senior
quality analysts' investigation
• Review patient safety events in
RL relating to lab errors
• Identify failure points
• Visit clinics and follow the
specimens from the clinic to the
lab
• Interview staff and leaders
• Complete a root cause analysis
METRIC CATEGORIES COMPARED
• 30-60-90-day plan
• After implementing the
selected action plans, we will
check in to see how the action
plans are impacting the lab
specimen process
• 30 days = 95%
• 60 days = 97%
• 90 days = 100%
DISCUSSION
• PICOT: In the Sharp Rees-
Stealy clinics, how do the
suggested process
improvements compared to the
current process impact the
number of lab errors within 3
months?
• There are several ways a system
can improve its process; we
need to identify where the
failure points are
NEXT STEPS & OPPORTUNTIES
• Next Steps: review findings with
leadership and share suggestions
for improvement
• Changes to EHR, creating
critical task area, send all
specimens to Copley
• Evaluation and monitor: After
leadership implements their
action plan, we will monitor RL
and labs to ensure that goals are
being met