The Institute of Medicine (IOM) will soon publish (on September 22, 2015) another follow-up to their 1999 report, "To Err is Human."
This new report will include an examination of diagnostic errors, their etiology and their prevention. With more than 1000 deaths and 10,000 serious preventable adverse events occurring per day, combined with the more than $1 trillion dollars lost annually attributed to these errors, healthcare leaders must commit every day to better and safer care – and deliver.
The CDC reports that laboratories play a critical role in healthcare with lab data representing 60% of the medical record and informing 60-70% of medical decisions. As clinical processes become more complex, the number of preventable adverse events seem to increase; because of this, the laboratory will receive a new level of scrutiny in its processes, accuracy and output as it relates to the accuracy or timeliness of a patient diagnosis and/or treatment. Technology is one way to bridge the gap between human error and zero errors, greatly improving patient safety when used correctly. Errors in specimen and transfusion management are costly, endanger patients, decrease reimbursement, can damage a hospital's reputation, and yet, they are 100 percent preventable.
Achieving an error-free laboratory management and total testing process lies in the implementation and adoption of closed-loop systems and processes, which are driven by advanced technology. Through assessment and integration of people needs as well as process needs, organizations can better manage increasing complexity and fill the gap between human and zero error. Eliminating avoidable mistakes through positive patient identification (PPID), printing and affixing specimen labels in the presence of the patient and transfusing the right blood components to the right patient without delay creates a more efficient environment, increases productivity and dramatically enhances patient – and clinician – safety.
The Challenge of Getting to Zero Errors
Hospitals and healthcare systems are facing critical and ongoing business and clinical issues, including decreasing reimbursements, higher patient volumes, a stringent regulatory environment and the increasing sophistication of lab operations, all of which contribute to more burden and pressure on healthcare professionals to improve quality while reducing cost and error.
As technology develops and processes become more complex, safe specimen and transfusion management requires the involvement of a greater number of people and departments in order to ensure safety, accuracy and consistent high levels of quality. Contributing to the lab's quality and cost challenges is an aging workforce, where highly experienced professionals are retiring faster than new staff is able to onboard to efficiently perform these operations.
In addition to growing workforce demands, laboratory processes continually become more advanced and often more complex. As complexity increases so does the statistical probability of errors. Some of the increased complexity is a result of redundancy, double-checking and documenting of manual processes to ensure each step in the testing process is being followed correctly.
In a 2012 article by Dr. Robert Hawkins, he notes that the total testing process (TTP) consists of a "series of activities that have traditionally been separated into three phases, pre-analytical, analytical and post-analytical." Hawkins suggests that it is more appropriate to consider this a five-phase process (adding an additional pre-analytical and post analytical phase) and in doing so, he notes – with some alarm - that true error rates are substantially higher than in the traditional three phase measures. The lab is the quality leader throughout the hospital. When the lab controls the TTP, consistently higher quality results than when other departments become involved. Because organizations require multidepartment workflows in the specimen and transfusion management processes, technology can ensure that the high quality started in the lab stays consistently high.
Because the TTP continuum crosses a multitude of departments, handoffs are inevitable. Every hand-off breaks the chain of custody, increasing the possibility for errors and creating a patient safety risk.
Closed Loop Processes and Technology Prevents Errors
In contrast, a closed loop approach eliminates hand-offs requiring relabeling between departments, while reducing redundancy and time to results. From a cost and quality perspective, the system ensures all steps are complete and correct the first time. Closed loop solutions create a more efficient team, ultimately speeding up productivity while eliminating errors, effectively reducing Turnaround Time (TAT) and delayed or mis-diagnosis—saving lives, money and time. Comprehensive specimen tracking capabilities and complete visibility from the bedside to the lab or to a transfusion can make the difference between timely disposition of diagnosis and treatment, appropriate length of stay (LOS) and increased system cost, care excellence and error.
Since 20 percent of all transfusion errors are a result of patient misidentification or specimen mislabeling during the initial specimen collection for type and crossmatch, barcode scanning transforms a slow manual process – especially in the ED where every second counts – into a high efficiency process with as little as three steps (scans). Since the system automates each step and provides electronic verification, it eliminates the need - and the time – to wait for a second nurse or other resource to double check a task. Automation manages every component across every department and "builds in" the ability for nurses to know everything from how to manage the specimen, right down to the order in which the tubes should be drawn. From a reimbursement perspective, the system gathers all of the relevant metrics and data that hospitals need for full and timely payment.
Eliminating Preventable Errors
A closed loop system creates a lean management method and allows complete traceability, locating a specimen at any time or place, reducing hand-offs and ensuring total accountability to document all lab care for patients. Blood transfusion and specimen management errors are preventable through technology; this fact addresses the "human factor" in a complex process. Hospital leaders can implement new strategies today to improve patient safety, protect care professionals, reduce risk, improve productivity and efficiency and take cost out of two high volume and high error procedures.
Closed loop blood and specimen management is an opportunity for healthcare executives to create a process free of error. Hospital leaders have unique and challenging roles, responsible for patient care, safety and cost, while creating efficiency in care delivery. They also hold themselves personally accountable for reducing – and preventing – needless patient suffering. Patients enter the healthcare system in trust that they will stay safe and will not be harmed, and the healthcare leader always acts to fulfill that trust.
While "to err is human", the use of technology provides an opportunity to remove preventable human error from specimen and transfusion management, thus keeping the patient and the organization safe.
JoAnne Scalise MS-Patient Safety Leadership, RN, is personally and professionally committed to patient safety and clinical excellence. In her role as Sunquest Information System's Manager of the Nurse Consultant team, she ensures that patient safety, nursing workflow and care excellence –as well as nurse and clinician safety – are always at the core of all Sunquest specimen and transfusion management solutions. She has extensive experience in adult and neonatal critical care, patient safety, quality, and nursing leadership at the national level. JoAnne has presented nationally on patient safety, clinical adoption of Health IT, quality, leadership, program development and effective communication. JoAnne received her Masters of Science in Patient Safety Leadership from the University of Illinois at Chicago College of Medicine and her BSN and RN many years before that.
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