Patient Safety--plain version--Alaska March 2012(1).pdf

8/9/2019 Patient Safety--plain version--Alaska March 2012(1).pdf

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Tools to Improve Patient Safety in

Medical Laboratory Services

Catherine Otto, Ph.D., MBA, MLScmPresident

American Society for Clinical Laboratory ScienceMarch 29, 2012

Anchorage, Alaska


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Objectives

Summarize the six aims of the Institute of Medicine toimprove the quality of medical laboratory services.

Discuss one methodology for measuring improvementto the pre and post-analytic phases of laboratoryservices from the perspective of the six IOM aims.

Identify one metric for the pre and post-analyticphases of medical laboratory services to monitorpatient safety.


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Patient Safety

freedom from accidental injury:

avoidance, prevention, & amelioration of

adverse outcomes or injuries stemming from

the process of care. IOM. To Err is Human


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Health Care Quality

The degree to which health services for

individuals and populations increase the

likelihood of desired health outcomes and are

consistent with current professional

knowledge. IOM, Crossing the Quality Chasm


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Potential for Healthcare Errors

Multiple, varied interactions with technology

Many individuals involved in the care; multiplehand-offs for care

High acuity of illness or injury Ambient environment prone to distraction

Need for rapid decisions; time pressured

High volume, unpredictable patient flow

source: National Forum for Health Care Quality Measurementand Reporting


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IOM Definition of error

Failure to complete a planned action as

intended [error of execution]or

the use of a wrong plan to achieve an aim

[error of planning]


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Errors occur

Frequently performed processes

Use previously formed actions, responses, behaviorautomatic, effortless

Interruption, fatigue, time pressure, anger, anxiety,

fear, boredom Problem-solving processes

Requires conscious & controlled cognitiveprocessingslow, lots of effort, difficult & highlycognitive

Misinterpretation of the problem to be solved, lack ofknowledge, habits that cause us to see what weexpect to see


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How errors occur

Frequently performed processes

Slipswrong automatic action

Lapseomission of automatic action

Problem-solving processes

Mistakesselect incorrect goal; use incorrect

procedure/rule; lack of knowledge


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Types of Errors

Diagnostic

Error (FP) or delay in diagnosis (FN)

Failure to employ indicated tests (FN)

Use of outmoded tests or therapy (FP or FN)

Failure to act on results of monitoring or testing


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Types of Errors

Treatment Error in the performance of an operation,

procedure, or test (FP or FN)

Error in administering the treatment Error in the dose or method of using a drug

Avoidable delay in treatment or in responding toan abnormal test

Inappropriate (not indicated) care


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Types of Errors

Preventive Failure to provide prophylactic treatment

Inadequate monitoring or follow-up to implement

necessary treatment

Other Failure of communication

Equipment failure Other system failure


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Test Ordering Errors

Underuse: error of omission

Failing to order a necessary test for a clinicalcondition

Overuse: error of commission

Ordering tests unnecessarily

Misuse

Ordering the wrong test for the clinical condition


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Aims of the Institute of Medicine

Safe: avoiding injuries to patients from thecare that is intended to help them

Effective: providing services based onscientific knowledge to all who could benefit

and refraining from providing services tothose not likely to benefit (avoiding underuseand overuse).


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Patient-centered: providing care that is respectful of and

responsive to individual preferences, needs, and values and

ensuring that patient values guide all clinical decisions.

Timely: reducing waits and sometimes harmful delays for

both those who receive and those who give care.


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Efficient: avoiding waste, including waste ofequipment, supplies, ideas, and energy.

Equitable: providing care that does not vary inquality because of personal characteristics

such as gender, ethnicity, geographic location,and socioeconomic status


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Laboratory Quality is

Performing the correct test

On the correct patient

At the correct time At the least cost

With the best outcome.


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Do we know if?

The correct/best test is performed for the patientscondition or situation.

The test is performed on the correct patient.

The test it performed at the correct time to captureappropriate information.

At the least cost.

The patient achieves the best outcome.

The patient is adversely harmed in any manner.


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Total Testing Process

Pre-analytic Analytic Post-analytic

Clinical question Sample is

prepared

Laboratory test

result is reported

Laboratory test is

selected

Analysis is

performed

Clinical answer is

determined

Laboratory test isordered

Test result isverified

Action is taken

Specimen is

collected

Effect on patient

outcome


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Errors in Pre-analytical Phase

Clinical question

Inadequate patient historywrong clinical question;fail to consider appropriate clinical question

Test selected

Incorrect test selected for clinical question; Test ordered

Incorrect timeof day, in disease process

Specimen collected

Unlabelled, mislabeled, mishandled, wrong type ofspecimen collected; patient not appropriatelyprepared


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Errors in Analytical Phase

Sample prepared

Inappropriately handled

Analysis performed

Instrument failure, instrument out of control,misidentification of sample with result

Result Verified

Abnormal values not checked, not noticed


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Errors in Post-Analytical Phase

Result reported

Not delivered to correct individual, delay indelivery

Clinical answer

Inappropriate conclusion with respect to testresult & clinical question

Action taken

Inappropriate, no or too much action taken

Effect on patient care

Patient outcomes (live, die, disability,decrease/increase in quality of life)


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Aim: Safe

Avoiding injuries to patients from the care

that is intended to help them

First and last steps in the laboratory testing

process (Total Testing Process)greatest risk

for harm to the patient:

selecting the correct test to perform

Accurately interpreting test results


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Safe: pre-pre analytic

Selecting the correct test to perform

Test selection guidelines

Based upon Evidence-Based Medicine

Uses clinical evidence

Reflexive testing protocols

Based upon Evidence-Based Medicine

Clinical guidelines Based upon Evidence-Based Medicine

Based upon Evidence-Based Management


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Safe: measures of deficiencies

Pre-analytic:

Incorrect test orderedwrong test performed

Incorrectly identified patient

Incorrectly collected samples

Incorrectly labeled samples

Incorrectly processed samples

Improperly performed phlebotomy


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Safepreanalytic

Do not harm patients while in our care

phlebotomy success rate

Reasons for lack of success:

Not-fasting

Order missing information

Difficult to draw

Patient left the collection area

Improperly prepared Patient presented at the wrong time

Arch Pathol Lab Med 2002; 126: 416-419


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Safepreanalytic

Reasons for specimen rejection

Hemolyzed

Insufficient quantity

Clotted

Lost or not received in the laboratory

Inadequately labeled


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Safetypreanalytic

Wrist band error rate

Average 7.40% at beginning of study

Average 3.05% at end of 2 year study

71.6% of errors due to missing wristband

Error rate improves when refused to draw sample if

wrist band missing, or inaccurate

Arch Pathol Lab Med 2005; 129:1252-1261


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Safepreanalytic

Blood culture contamination rate

Significantly higher in institutions without a

dedicated phlebotomy team (i.e. non-

laboratory personnel)

Higher volumes of blood collected had lower

contamination rates Arch Pathol Lab Med 2005; 129: 1222-1225


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Analytic:

Incorrectly labeled sample

Incorrectly performed analyses

Incorrectly performed calibration

Incorrectly performed quality control

Incorrectly performed proficiency testing

Incorrectly recognizing an abnormal test result


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Safeanalytic

Bedside glucose monitoring program

A study using split samplesfor laboratory & glucose

POCT program

45.6% results differed by > 10% 25% results differed by > 15%

14% results differed by > 20%

3.3% results were reported when qc either out ofrange or not performed

Arch Pathol Lab Med 2005; 129-1262-1267


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Post-analytic:

Incorrectly recognized abnormal test result

Incorrectly handled critical value reporting

Incorrectly handled critical test reporting

Abnormal test result not recognized by clinician

Test result not interpreted correctly by clinician

Lack of appropriate follow-up for abnormal testresult


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Safepost analytic

Critical value notification

More than 45% of critical values wereunexpected

65% resulted in a change in therapy Not universally defined:

Critical tests

Critical valuesArch Pathol Lab Med 2002; 126:663-669


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Safe: post-analytic

Accurately interpreting test results

Estimated 5% of medical errors related to

misinterpretation of test results

Hemolyzed specimens30% of residents were

confident interpreting test results with

comments regarding presences of hemolysis

J Clin Pathol 2009; 62: 664-666


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Safe--measures of deficiencies

Effective utilization of test results

Incorrect interpretation of test results

Failure to order follow-up laboratory test(s)

Continuing to re-order the same laboratory test Outcomes of laboratory testing

Failure to follow a best practice protocol

Failure of clinician to notify patient of abnormal test

results and advise of subsequent next steps Harm to patientdelay in diagnosis, misdiagnosis,

decrease in quality of life


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Aim: effective

providing services based on scientificknowledge to all who could benefit andrefraining from providing services to those not

likely to benefit (avoiding underuse, overuse,and misuse)

Greatest opportunity to improveeffectiveness:

selecting the correct test to perform

accurately interpreting test results


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Effective: pre & post analytic

Evidence-based Laboratory Practice (EBLM)

Test selection

Coagulation testing

Molecular testing

Therapeutic drug monitoring

Test result interpretation

Coagulation testing


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Effectiveness

Frequency of glycosylated hemoglobin

Study of 212 institutions

31.3% patients monitored quarterly

64.9% monitored at least semi-annually

More frequent monitoring experienced greaterreductions of A1c levels

Sending reminders associated with greater semi-

annual monitoring & tighter control Arch Pathol Lab Med 2001; 125: 191-197


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Effectiveness

Heparin therapy monitoring

Study of 140 institutionsfrequency of either APTT or FactorXa level performed at least 1x within 12 hours of heparinadministration

87% of labsa platelet count performed within 72 hours ofheparin administration

78% achieved therapeutic anticoagulation within 24 hours ofadministration

Arch Pathol Lab Med 2004; 128: 397-402


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Improving measurement of

effectiveness Reporting of overused, underused and misused laboratory

tests

Report testing performed for screening procedures

Report testing performed to monitor chronic diseases

Report rates of diagnoses of disease

Share with patients current standards care for laboratory testand diagnosis or condition


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Aim: patient-centered

providing care that is respectful of and

responsive to individual preferences, needs,

and values and ensuring that patient values

guide all clinical decisions


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Patient-centered: pre-pre analytic

Education of clinicians and patients about

ordered laboratory tests

Consult with clinicians & patients

Provide educational materials

Instruct patients on proper preparation for

specimen collection


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Patient-centered: pre-analytic

Pre-analytic:

Recognition of cultural differences

Sample collection

Educate regarding the how & why of process Describe sample collection process

Share how to care for themselves after collection

Collect information on # of adverse collection events

Evaluate customer service Collect # of samples collected per patient


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Patient-centered: analytic

Change the measurement focus from specimens or

tests performed to # of patients

Monitor number of patients served instead of # of

tests performed Monitor # of tests performed per patient

Monitor # of abnormal test results

Monitor # of critical test results Monitor # of critical tests that are abnormal


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Patient-centered: post-analytic

Provide patients with appropriate informationto understand their laboratory test results

Send all laboratory test results directly to each

patient Send all screening test results to patients

Send all abnormal, critical value & critical test

results to patients Send all test results performed with 24 hours

of discharge from hospital to patient

f


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Improving measurement of patient-

centeredness

Change focus from specimens to patients

Coordinate care among laboratory disciplines

(areas)

Provide educational materials for patients that

are prepared by the laboratory


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Aim: timely

reducing waits and sometimes harmful

delays for both those who receive and those

who give care


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Timely: how to measure?

It is time to measure laboratory timeliness from an external focusthe patient & the clinician

Need a standardized definition to measure turn-around-time:

Time from patient receiving test order from clinician until action istaken from the perspective of the patient

Time from clinician ordering test to clinician taking action on testresult

Time from sample collected to clinician taking action on test result

Time from sample collected to reported to clinician


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Improving measurement of timeliness

Choose the most important &/or the highestvolume laboratory testsreport their TAT

Report TAT for laboratory tests performed for

patients in surgery, ICU, ED, oncology

Communicate problems to customersimmediately

Incorporate point-of-care testing modalities toimprove patient outcomes


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Expand the definition of turn-around-time toinclude:

Time of sample collected to action taken by

clinician Time of test ordered (or interaction with clinician)

to action taken by clinician

Measure and report time to treatment or timeto next diagnostic procedure


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Pre-analytic:

Implement methods to decrease the time from

test ordered to specimen received in the

laboratory Post-analytic:

Implement methods to decrease time from when

the test is completed to an action is taken on thepatients behalf


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Aim: efficient

avoiding waste, including waste of

equipment, supplies, ideas and energy


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Efficient: pre-analytic

Missed phlebotomy collectionsmultiple

attemptsdifficult draw

Multiple sample collections due to improper

or inadequate sample collected

Mislabeled samples

Unlabeled samples

Lost samples


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Efficient: analytic

Repeat testinge.g. due to problems with

instrument, quality control, sample

Repeat testingtests repeatedly ordered

within a short timeframeinitiated byclinician

Repeat testinganalytes or parameters that

do not change rapidly


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Efficient: post-analytic

More than one attempt to contact clinician

with results from a critical test, critical value,

or abnormal

Mix-ups in reportingsending the report tothe wrong clinician


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Improving measurement of efficiency

Measuring:

Repeat testing (laboratory related)

improvementsavings

Repeat testing (clinician related)improvementsavings

Associate inefficiencies with system outcome

LOSdecrease ED bed turnover rate


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Improving measurement of efficiency

Report deviation in consistent manner

Use a common denominator

Per label, percentage, per billable test, per specimen

Calculate each phase, individual step Pre-analytic, analytic, post-analytic

Link to effect upon healthcare delivery system

Increased cost

Delays to patient care

Harm to patient


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Equitable: care that does not vary

Expand access to phlebotomyevenings &

week-ends

Expand access to testingone-stop clinics,

pharmacies

Report variability of testing between POCT

and clinical laboratory methodologies


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Aim: equitable

providing care that does not vary in quality

because of personal characteristics such as

gender, ethnicity, geographic location, and

socioeconomic status


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Equitable: pre-analytic

Expand access to phlebotomy

Evenings & week-ends

Communication services

Translation services, bilingual employees

Educational materials in appropriate

languages for patient population

Educational materials at appropriate literacy

level


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Equitable: post-analytic

Educational materials How to care for phlebotomy site

What do test results mean

www.labtestsonline.org

Send test results directly to patients

Dependent upon state lawssome states allowpatients to request directly from the laboratory

Consultative services

Doctorate in Clinical Laboratory Science
http://www.labtestsonline.org/http://www.labtestsonline.org/


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Improving measurement of equity

Report variability of testing between POCT and clinicallaboratory methodologies

Provide educational material at appropriate readinglevel

Provide educational material in multiple languages

Report statistics stratified by demographics (gender,ethnicity, geographic location & socioeconomic status)


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Procedure to Evaluate Laboratory

Services that Impact Patient Safety


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Step 1: Areas of Risk

Determine area(s) of risk: Identify those that pose the greatest risk of harm

to your patients

Sources to identify harm: Patient safety alerts

Published literature

Patient safety officer

Phone calls from clinicians

Patients

Reports from laboratory personnel


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Step 1 (continued)

Ask and answer:

Who

What

Where

When

Why

How


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Potential for Errorsareas to improve

In which systems (disease processes) does

medical laboratory test information have the

greatest impact?

High volume, high cost, high risk

Where are the critical hand-offs, i.e. the

circumstances where the information is used

immediately?

Use the Total Testing Process as a foundation


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Step 2: Data Collection

Select a few Patient Safety Indicators

Focus upon:

One phase of laboratory testing

All three phases

One IOM aims

More than one IOM aim Represent all testing areas


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Data Sources for Error Collection

Institution incident reports

CQI/PI monitoring data

Patient safety requirements for The Joint

Commission

TAT studies---outliers

Phone log for complaints from clinicians &

patients


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Resources & Sources of Data

Administrative data: HIS, LIS, billing systems

Medical/health records: electronic & paper

Laboratory test results: LIS

Logs: electronic & paper

Surveys: users (clinicians, nurses), patient


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Attributes of Administrative Data

Patient demographics

Hospital & clinician information

Hospital length of stay (LOS)

Codes for diagnosis & co-morbidities

Codes for principal & other procedures

Payment source


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Confidentiality & Data Collection

Patient confidentiality is critical

HIPAA: consult your risk management, quality

improvement & legal departments

IRB: institutional review board for studies

involving human subjects


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Step 3: Denominator

Determine denominator to calculate error rate

Critical to calculate effect of intervention & to

compare error rates among laboratory

disciplines

Patient-centered focus:

Number of patient encounters

Adjusted patient days


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Denominators

Non-hospital setting

Event per patient encounter basis

Denominator: number of patient encounters

Hospital setting

Event per adjusted patient day

Denominator: adjusted patient days


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Step 4: Capture Data

Length of time to collect data Week, month, quarter, year

Dependent upon: frequency of error

Technology support Spreadsheet or database

LIS/HIS

IT department Secondary purpose: representation of data to

share with other departments


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Step 5: Measure Outcomes

Link (measure associations) errors and error ratesto an outcome:

Delayed diagnosis

Delayed treatment Incorrect diagnosis

Increased cost

Sequelae

Length of stay (LOS)

Emergency bed turnover rate


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Outcome of health care process

The best measure of quality is not how well

or how frequently a medical service is given,

but how closely the result approaches the

fundamental objectives of prolonging life,relieving distress, restoring function, and

preventing disability. Lembcke

source:Am J Public Health1952 42:276-286


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Goal of health care process

Achieve the WHO definition of health:

a state of complete physical, mental, and social

well-being and not merely the absence of disease

or infirmity

By fully implementing the 6 IOM aimssafe,

effective, timely, efficient, equitable andpatient-centered


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Outcome of Laboratory Testing

Live; get well; improve health/function Die; dont return to previous state of health

Cured; remission; out of remission

Treatmentsurgery, medication Change treatment; medication adjustment

Indicator of disease progression

Hospital admission; hospital discharge Peace-of-mind

f


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Two perspectives of Outcomes

System-related outcomes:

Outcomes from the perspective of the health care

system, managed care plan, institution,

department

Patient-related outcomes:

Impact or result of the intervention on thepatients outcomes, viewed from the patients

perspective

l d


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System-related Measures

Administrative outcomes:

Process and outcome measures based on

administrative aspects of the intervention

Economic consequences:

Process and outcomes measures based on the

administrative aspects of the intervention

l d


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System-related Measures

Process

Administrative process of care

Economic consequences of administrative

processes

Outcome

Administrative outcomes of care delivery Economic consequences of administrative

outcomes

Laboratory Administrative Processes of


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Laboratory Administrative Processes of

Care

Duration of therapydays, hoursCompliance ratereceive meds at appropriate

time--#, % Length of infectiondays, hours

Length of ICU &/or hospital staydays, hoursReduction in length of therapytime, %Reduction in ICU staytime, %Reduction in hospital staytime, %

% samples tested at appropriate time Tests per TDM episode--# Tests per thrombotic episode--#

Laboratory Administrative Outcomes


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Laboratory Administrative Outcomes

of Care

% TDM test results within therapeutic range

% increase of test results within therapeutic

range

% coagulation tests within therapeutic range

for inpatient thrombotic event

Laboratory Economic Consequences of


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Laboratory Economic Consequences of

Administrative Outcomes

# readmissionscost; $ saved; % change

Cost per hospitalization--$ saved; % change

Cost per episode of care--$ saved; % change

P i l d M


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Patient-related Measures

Clinical

Patients clinical status as a result of intervention

Health-related quality of life:

Impact of health status on various domains

L b Cli i l O f C


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Laboratory Clinical Outcomes of Care

Incidence of toxic effects--#, % change

Therapeutic level rate--% change

# of septic episodes--% change

Reduction of symptoms--#, % change

Curerate, % change

Mortalityrate, % change Morbidityrate, % change

St 6 D t A l i


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Step 6: Data Analysis

Examine the data using quality/processimprovement techniques:

The 5 whys

Answer the who, what, where, when, why and

how questions

St 6 ( ti d)


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Step 6: (continued)

What do these data mean?

How are the data trending? Is the error rate

increasing or decreasing?

Have there been any reports of patient harm

as a result of these events?

Were there any near-misses?

Were there any never events?

Is this rate of errors acceptable?

B fit f D t A l i


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Benefits of Data Analysis

Objective information to determineintervention.

Within the laboratorychange the process,

re-train, purchase new equipment, etc.

Outside the laboratorydata to demonstrate

problem---important to focus how errors

impact larger system Use to compare pre and post intervention.

St ti ti l P


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Statistical Program

Excel, SPSS, others

Descriptive Statistics

Mean, mode, range

Evaluation

T-test (continuous variables), Chi Square

(categorical variables)

St 7 D i I t ti


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Step 7: Design an Intervention

Consider one change at a time Incremental change is the most sustainable

Conduct a pilot study first

Pre and post intervention measurements are

critical

Method of collection needs to be identical

Denominator must be identical

St 8 F ll U


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Step 8: Follow-Up

Continue to monitor error rate for identifiedindicators

When error rate is acceptablemove to

examine other indicators

Monitor original indicators periodically


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Example:

Specimen Collection Success RateWhat can go wrong in this process?

Errors in Specimen Collection Process


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Errors in Specimen Collection Process

Patient not educated in specimen collectionmethod

Stool, urine, semen, blood

Patient not prepared for specimen collection Fasting/non-fasting

Patient not identified accurately

Wrong specimen collected

Specimen collected improperly

Error in Specimen Collection Process


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Error in Specimen Collection Process

What happens when that occurs? Re-collection

Increase in costlabor (repeat work)

Delay in diagnosistreatment, diagnosis,admission, discharge

Increase in hospital stay (LOS)

Measuring Outcome of Wrong Specimen


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g g p

Collected

Administrative process of care #/% of re-collected samples (number, rate)

Administrative outcomes of care

Change in admission time (number, rate)

Change in discharge time/date (number, rate) Delay in diagnosis/treatment (number, rate)

Economic consequences of administrative outcomesof care

Change in cost for labor & equipment forrecollected samples

Measuring Outcome of Wrong Specimen


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g g p

Collected

Clinical Change in diagnosis/treatment

Data to Collect


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Data to Collect

Errors in specimen collection: # errors & totalsamples collected

Reason why specimen needed to be re-collected5categories of errors (see previous slide)

Specimens that are re-collected

Verify that those that needed to be re-collectedwere re-collected

Patient information: age, gender, diagnosis,co-morbidities, clinician, in or outpatient

Who re-collected the samplelab, other

Data to Collect


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Data to Collect

Labor and supply costs

Delay in actiontreatment, diagnosis,

admission, discharge

Length of stay

Data Collection


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Data Collection

Depends upon how often errors occur Sample size needs to be large enough to examine

differences

Retrospectiveexamine last years statistics to

determine administrative process & outcomes andeconomic consequences of specimen collectionerrors

This serves as the baseline for comparison afterintervention implemented.

Example


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Example

Sample collection error rate:

10 errors/ 1000 samples collected

7500 samples collected/day= 75 errors/day

Example


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Example

Reason for specimen collection error:

Patient not educated: 2/1000 specimen collected

Patient not prepared: 3/1000 specimen collected

Patient inaccurately idd: 1/1000 specimencollected

Wrong specimen collected: 2/1000 specimen

collected

Specimen collected improperly: 2/1000 specimen

collected

Example


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Example

Specimens recollected: 8 recollected/10 specimen collection errors

Patient not educated: 2/1000 specimen collected[1/2]

Patient not prepared: 3/1000 specimen collected[2/3]

Patient inaccurately idd: 1/1000 specimen collected[2/2]

Wrong specimen collected: 2/1000 specimen

collected [1/2] Specimen collected improperly: 2/1000 specimen

collected [2/2]

Example


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Example

Patient data:

50% male; 50% female

60% > 65 years

20% 20-65 years 10% 10-20 years

10% < 10 years

90% inpatients; 10% outpatients 50% ED, 10% ICU, 30% medical, 10% POL

Example


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Example

Who collected improperly collected sample: 70% collected by non-laboratory personnel (60%

in-patient, 10% outpatient)

30% collected by phlebotomist

Who collected re-collected sample:

75% collected by phlebotomist

25% collected by non-laboratory personnel

Example


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Example

Labor & supply costs for re-collected samplescollected by laboratory staff

Labor: $4.25 per re-collected sample

Supplies: $0.75 per re-collected sample

7500 samples/day x 365 days = 2,737,500 samplesper year

6/1000 re-collected by phlebotomist (75% ofrecollected)

.006 x 2,737,500 = 16,425 samples recollected $5.00 x 16,425 = $82,125

Example


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Example

For those in the ED (50% of recollected samplesfrom ED)4 re-collected sample/1000 collected

Delay in admission: 50% by 60 minutes

Delay in discharge: 50% by 90 minutes .004 x2,737,500 = 10,950 patients delayed in ED

5,475 by 60 minutes; 5,475 by 90 minutes

228.125 days; 342.1875 days (24 hour clock)

Practice:


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Practice:

Misidentification of sample

Communication of test result

Wrong test ordered

Turn-around-time (timeliness)

Ineffective utilization of test results


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What happens when error occurs?


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What happens when error occurs?

Outcome Measurement of Error


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Outcome Measurement of Error

Administrative process of care

Administrative outcome of care

Economic consequences of administrative

outcomes of care

Data to Collect


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Data to Collect

Final Comments: Share Your Successes


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Final Comments: Share Your Successes

Prepare summary of successQI report foraccrediting/regulatory organizations

Share at local, state, national meeting

Poster, oral presentation

Publish ASCLS Today, CLS, other journal

ASCLSPatient Safety Committee Goal: repository on www.ascls.org

Resources at www ascls org
http://www.ascls.org/http://www.ascls.org/


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Resources at www.ascls.org

Participate---Patient Safety

Patient Safety Tips Venipuncture

Fasting

Glucose tolerance test

Hydrogen breath test Personal Pocket Laboratory Guide

Patient Safety Resources Patient safety websites

Procedure Publications

Education

Contact Information
http://www.ascls.org/http://www.ascls.org/


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Contact Information

Catherine Otto, PhD, MBA, MLS

[email protected]
mailto:[email protected]:[email protected]

Patient Safety--plain version--Alaska March 2012(1).pdf

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