Medical Errors and the Laboratory: How Healthcare Organizations are Improving Rates and Improving Patient Care

Errors in medicine have been a common occurrence since the birth of medicine, but have been brought to light more recently as more patients are becoming more active in their own care. Errors which involve the laboratory can be catastrophic for a patient, as a wrong test result can alter the entire treatment plan a physician implements. Healthcare organizations and accrediting organizations have become diligent about tracking errors and the most common sources of error, so that new policies, procedures, and technology can be implemented in order to reduce errors. The laboratory itself has made many strides in error prevention, but has encountered hurdles due to the difficulty of tracking errors that occur within the walls of the laboratory. Different steps which occur in the total testing process, or TTP, have been identified to better track sources of errors, and to better focus methods of which to prevent errors. The different steps of the total testing, the pre-analytical, analytical, and post-analytical phases of testing have drastic differences in the amount of errors that occur in each step. The step where the majority of errors occur is the pre-analytical phase, which consists of patient identification, specimen collection, and transport of specimens to the laboratory. Due to the large number of errors that occur in this phase, particularly with patient identification, healthcare organizations have begun to implement barcode technology for patient identification, medication distribution, blood transfusions, and labeling of specimens collected from the patient. Errors have been reduced greatly over the past several years, but there is still a long way to go to prevent all errors from occurring in patient care

Performance criteria and quality indicators for the post-analytical phase

Background: Quality indicators (QIs) used as performance measurements are an effective tool in accurately estimating quality, identifying problems that may need to be addressed, and monitoring the processes over time. In Laboratory Medicine, QIs should cover all steps of the testing process, as error studies have confirmed that most errors occur in the pre- and post-analytical phase of testing. Aim of the present study is to provide preliminary results on QIs and related performance criteria in the post-analytical phase. Methods: This work was conducted according to a previously described study design based on the voluntary -participation of clinical laboratories in the project on QIs of the Working Group "Laboratory Errors and Patient Safety" (WG-LEPS) of the International Federation of Clinical Chemistry and Laboratory Medicine (IFCC). Results: Overall, data collected highlighted an improvement or stability in performances over time for all reported indicators thus demonstrating that the use of QIs is-effective in the quality improvement strategy. Moreover, QIs data are an important source for defining the state-of- the-art concerning the error rate in the total testing process. The definition of performance specifications based on the state-of-the-art, as suggested by consensus documents, is a valuable benchmark point in evaluating the performance of each laboratory. Conclusions: Laboratory tests play a relevant role in the monitoring and evaluation of the efficacy of patient outcome thus assisting clinicians in decision-making. Laboratory performance evaluation is therefore crucial to providing patients with safe, effective and efficient care

Evaluation of Laboratory Performance, Associated Factors and Staff Awareness Towards Achieving Turnaround Time in Tertiary Hospitals, Ethiopia

BACKGROUND: WHO recommends that each laboratory should establish turnaround time (TAT) to monitor and evaluate performance throughout processes. The status of established TAT was not yet assessed in Ethiopian Armed Force Comprehensive Specialized Hospital. The aim of this study was to evaluate the laboratory performance and associated factors towards achieving TAT in clinical chemistry and hematology tests at Armed Force Comprehensive Specialized Hospital, Addis Ababa, Ethiopia.METHODS: Hospital-based cross-sectional study was conducted from April 2019 to June 2019. Standardized questionnaire was designed to collected data on awareness of laboratory staffs about TAT. The data was entered, cleaned and analyzed using SPSS version 24.0 Software. Logistic regression analysis was done to find out statistically significant association and strength of association between dependent and independent variables at pvalue <0.05.RESULT: A total of 422 test results were systematically selected with 100% response rates. Of these, 253(59.9%) were chemistry tests. From the expected < 90min TAT clinical chemistry tests, only 41(16.2%) and from < 60min TAT time for hematology tests, 37(21.9%) met the target. The laboratory TAT was affected by factors including high work load, laboratory information system problem, power interruption and sample collection time. Moreover, the level of knowledge, attitude and practices of laboratory staffs towards laboratory TAT were 60%, 85.7% and62.9% respectively.CONCLUSION: Overall achievement of clinical Chemistry and hematology tests TAT was poor. The finding might reflect other public hospital situation in Addis Ababa. Thus, additional large scale studies need to conduct

Improving Emergency Department Length of Stay by Reducing Laboratory Turnaround Times

The purpose of this quality improvement project was to improve lab turnaround times to decrease Emergency Department (ED) length of stay. The project participants included registered nurses (RN) and medical doctors (MD) in the ED and medical technologists (MT), medical laboratory technicians (MLT), and phlebotomists in the laboratory. EDs are challenged with diagnosing and treating patients promptly and often encounter delays from outside factors. One of those includes laboratory turnaround times (TAT). Using lean methodology, interventions selected were put into place in an effort to decrease lab TAT. Standard workflows were developed for lab and ED team members. ED RNs began using ED protocols to enter pertinent lab orders during triage after assessing patients. ED RNs collected blood samples when starting their intravenous line, and a 5S was carried out to improve workplace organization. ED RN protocol usage improved by 14.7% the first month of the project and continued to improve for a final improvement of 68% compared to the 50% improvement target. The volume of blood samples collected by RNs improved from an average of 476 per month to 535 per month for an increase of 12% vs. a goal of 10%. Workplace organization improved from 8 points to 20 points compared to a goal of 15-20 points. Lab TAT for arrival to first ordered lab for CBCs, BMPs, and Troponins improved from an average of 20.85 minutes to an average of 18.53 minutes. Lab TAT from labs ordered to collection time for CBCs, BMPs, and Troponins also improved from an average of 19.88 minutes to an average of 17.37 minutes. This project improved the overall lab TAT by 4.82 minutes; however, it did not meet the ED LOS improvement target of 5%.D.N.P

Improving BNP turn around times in ED

Heart failure (HF) is one of the most common conditions in the United States. Cases of HF has immensely contributed to the number of patients visiting the emergency departments (ED) in healthcare facilities throughout the United States. Patient experience is impacted by several aspects, which includes the length of stay ( LOS) and quality of care outcomes. Literature shows that a delay in turn around times (Ekelund, 2014) in laboratory tests affects efficiency and other parameters of quality of healthcare. This project has been completed with the objective of identifying areas in clinical process that can be optimized to keep Betanatriuretic peptide (BNP) test results under a TAT of 60 minutes. Studies done by Hutchinson , 2017 showed SOB or dyspnea as a common presenting symptoms in the ED. The problem presented in this case is that the TAT for patients with undifferentiated dyspnea is higher, especially for those possibly suffering from HF and COPD. It is crucial to make an accurate diagnosis, which is why the time taken to confirm the problem in many cases is long. The specific description of interventions that would be made to the process includes: To reduce the number of hours taken to complete the lab results, to reduce the time it takes to upload results on the EMR database, and to shorten the time taken to complete the radiological tests. Methods employed included observation of TAT before and after intervention. The project featured several stakeholders in the internal and external environment that made up the project team. The project focuses on patients that reported to the ED with chief complaints of shortness of breath (SOB) as the primary basis for conductive comprehensive diagnosis. Findings of the project are vitals towards limiting costs and expenses tied to the ED, reducing the LOS and, improving care outcomes for patients diagnosed with acute congestive heart failure and thus reducing morbidity levels

Medical Laboratory Managers Success with Preanalytical Errors

Clinicians rely heavily on accurate laboratory results to diagnose and treat their patients. Laboratory errors can occur in any area of total testing phases, but more than half of the errors occur in the preanalytical phase. Framed by the total quality management theory, the purpose of this multiple case study was to explore medical laboratory managers\u27 strategies to reduce preanalytical errors. A purposive sample of 2 organizations with laboratories in southern California participated in semistructured face-to-face interviews. Company A had 2 participants and 3 participants participated in the study from Company B. Each participant had at least 5 years of laboratory experience, with a minimum of 2 years of management experience in preanalytical testing, and had completed one project to minimize laboratory errors. Thematic analysis exposed 5 main themes: quality improvement, recognition, reward, and empowerment, education and training, communication, and patient satisfaction. The participants highlighted the need for organizations to concentrate on quality management to achieve patient satisfaction. To achieve quality services, medical laboratory managers noted the importance of employee engagement, education and training, and communication as successful strategies to mitigate preanalytical errors. The recommendation for action is for laboratory leaders to review and apply effective strategies exposed by the data in this study to reduce preanalytical errors in their medical laboratory. Positive implications of this study include reduction of preanalytical errors, increased operational cost, and improved patient experience

Managing the Pre- and Post-analytical Phases of the Total Testing Process

For many years, the clinical laboratory's focus on analytical quality has resulted in an error rate of 4-5 sigma, which surpasses most other areas in healthcare. However, greater appreciation of the prevalence of errors in the pre- and post-analytical phases and their potential for patient harm has led to increasing requirements for laboratories to take greater responsibility for activities outside their immediate control. Accreditation bodies such as the Joint Commission International (JCI) and the College of American Pathologists (CAP) now require clear and effective procedures for patient/sample identification and communication of critical results. There are a variety of free on-line resources available to aid in managing the extra-analytical phase and the recent publication of quality indicators and proposed performance levels by the International Federation of Clinical Chemistry and Laboratory Medicine (IFCC) working group on laboratory errors and patient safety provides particularly useful benchmarking data. Managing the extra-laboratory phase of the total testing cycle is the next challenge for laboratory medicine. By building on its existing quality management expertise, quantitative scientific background and familiarity with information technology, the clinical laboratory is well suited to play a greater role in reducing errors and improving patient safety outside the confines of the laboratory

Defining a roadmap for harmonizing quality indicators in Laboratory Medicine: A consensus statement on behalf of the IFCC Working Group "laboratory Error and Patient Safety" and EFLM Task and Finish Group "performance specifications for the extra-analytical phases"

The improving quality of laboratory testing requires a deep understanding of the many vulnerable steps involved in the total examination process (TEP), along with the identification of a hierarchy of risks and challenges that need to be addressed. From this perspective, the Working Group \u201cLaboratory Errors and Patient Safety\u201d (WG-LEPS) of International Federation of Clinical Chemistry and Laboratory Medicine (IFCC) is focusing its activity on implementation of an efficient tool for obtaining meaningful information on the risk of errors developing throughout the TEP, and for establishing reliable information about error frequencies and their distribution. More recently, the European Federation of Clinical Chemistry and Laboratory Medicine (EFLM) has created the Task and Finish Group \u201cPerformance specifications for the extraanalytical phases\u201d (TFG-PSEP) for defining performance specifications for extra-analytical phases. Both the IFCC and EFLM groups are working to provide laboratories with a system to evaluate their performances and recognize the critical aspects where improvement actions are needed. A Consensus Conference was organized in Padova, Italy, in 2016 in order to bring together all the experts and interested parties to achieve a consensus for effective harmonization of quality indicators (QIs). A general agreement was achieved and the main outcomes have been the release of a new version of model of quality indicators (MQI), the approval of a criterion for establishing performance specifications and the definition of the type of information that should be provided within the report to the clinical laboratories participating to the QIs project

Defining a roadmap for harmonizing quality indicators in Laboratory Medicine: A consensus statement on behalf of the IFCC Working Group "laboratory Error and Patient Safety" and EFLM Task and Finish Group "performance specifications for the extra-analytical phases"

The improving quality of laboratory testing requires a deep understanding of the many vulnerable steps involved in the total examination process (TEP), along with the identification of a hierarchy of risks and challenges that need to be addressed. From this perspective, the Working Group “Laboratory Errors and Patient Safety” (WG-LEPS) of International Federation of Clinical Chemistry and Laboratory Medicine (IFCC) is focusing its activity on implementation of an efficient tool for obtaining meaningful information on the risk of errors developing throughout the TEP, and for establishing reliable information about error frequencies and their distribution. More recently, the European Federation of Clinical Chemistry and Laboratory Medicine (EFLM) has created the Task and Finish Group “Performance specifications for the extraanalytical phases” (TFG-PSEP) for defining performance specifications for extra-analytical phases. Both the IFCC and EFLM groups are working to provide laboratories with a system to evaluate their performances and recognize the critical aspects where improvement actions are needed. A Consensus Conference was organized in Padova, Italy, in 2016 in order to bring together all the experts and interested parties to achieve a consensus for effective harmonization of quality indicators (QIs). A general agreement was achieved and the main outcomes have been the release of a new version of model of quality indicators (MQI), the approval of a criterion for establishing performance specifications and the definition of the type of information that should be provided within the report to the clinical laboratories participating to the QIs project

Failure to review STAT clinical laboratory requests and its economical impact

Background: Failure to follow-up laboratory test results has been described as one of the major processes contributing to unsafe patient care. Currently, most of the laboratories do not know with certainty not only their rate of missed (or unreviewed) requests but the economical cost and impact that this issue implies. The aim of our study was to measure that rate and calculate the resulting costs. Material and methods: In January 2015, we checked in our Laboratory Information Management System (LIMS) for every emergency request from 1st July 2011 to 30th June 2014, if they had been reviewed by any allowed user or not. 319,064 requests were ordered during that period of time. Results were expressed as “ordered requests”, “missed requests” and its percentage. Additionally, total cost of missed requests was calculated in euros (€). “Non-productive days” were theorised (as the days producing requests that were not reviewed) based on these results. Results: 7924 requests (2.5%) were never reviewed by clinicians. This represented a total cost of 203,039 € and 27 “non-productive” days in three years. Significant differences between inpatients, outpatients and emergency department as well as different emergencies units were found after application of statistical analysis. Conclusions: In terms of resources, never reviewed or missed requests appear to be a not negligible problem for the clinical laboratory management. Electronic result delivery, with electronic endorsement to indicate follow-up of requests along with better systems of electronic requesting should be investigated as a way of improving patient outcomes and save unnecessary expenses