Co-Production-Supported Zero Harm Identification Initiative in the Ambulatory Care Setting

As part of a gold-innovated fellowship, our team identified that laboratory errors have emerged as a priority for the CHA to be addressed, as they can lead to inaccurate test results affecting patient care. The goals of this project is to achieve “zero harm” related to laboratory practices and revise processes geared toward accurate patient identification and mislabeled/unlabeled specimens. Incorporating the patient into the procedure and the testing is a critical component of our revised process.

Pre-analytical laboratory errors (defined as the time period from ordering to collection, up to the time the test is analyzed) account for up to 75% of all laboratory errors. 1 A retrospective analysis of safety reports (SERS) regarding laboratory issues filed during a period of three months, from 3/2018 to 6/2018, was performed utilizing a systematic review of 121 errors in the ambulatory care sites showed that 17.36% were related ordering, 16.53% to collection, 63.64% to transportation, and 2.48% to accessioning. These errors were analyzed to develop informed recommendations and practices to achieve the goal of “zero harm.” Of note, the lack of patient involvement was identified in the lab process.

1) Collaboration with the laboratory and ambulatory care clinics we will develop processes that incorporate both patients/family and staff to support “Zero Harm” initiatives.
2)    Identification errors are uncommon (55 per 1 million billable lab tests), but they potentially can have a significant impact on patient care.
3)    These errors can be a result of initial registration, order error, clerical error, primary specimen label error, aliquot error, or result entry error.

Identified the need to improve, patients/families were cited as key stakeholders. At a clinic, nurse manager and a nurse educator engaged staff in the lab to have the patient visually verify their name and date of birth at the time of collection. This simple process decreased labeling errors in that clinic to ZERO for a period of 296 days.

We have increased staff engagement and satisfaction with new tools we implemented.

Our team proposes working in a thoughtful and economical way that is future-orientated.

In conclusion as a high-reliability organization (HRO), we will continue to engage colleagues to use the safety report system (SERS) to support a culture of safety. Incorporating patients/family members and colleagues in the “zero harm” initiatives will reinforce the current culture of safety, ownership, and positivity. The team will continue supporting evidence-based procedures including the deployment of systems of safety in a consistent manner such as banding, barcoding and printing labels at registration. This process going forward will have a positive effect on the patient experience.

References
1)    McPherson, Richard and Pincus, Matthew; Henry’s Clinical Diagnosis and Management by Laboratory Methods 23rd edition, Chapter 3- Preanalysis, Elsevier 2017, Pg. 20.
2)    Batalden, supportsM. et al.BMJ Qual Saf 2015 :1-9. doi:10.1136/bmjqs-2015-004315
3)    Identification Errors Involving Clinical Laboratories A College of American Pathologists Q-Probes Study of Patient and Specimen Identification Errors at 120 Institutions Paul N. Valenstein, MD; Stephen S. Raab, MD; Molly K. Walsh, PhD Arch Pathol Lab Med—Vol 130, August 2006, p1108