Quality AssuranceQuality Assurance Positive Outcomes for Negative Positive Outcomes for Negative

EventsEventsQuality Assurance monitors Quality Assurance monitors

operational systems:operational systems: Pre-analyticalPre-analyticalAnalyticalAnalyticalPost-analyticalPost-analytical

Tools Used:Tools Used:QA MonitorsQA MonitorsPerformance ImprovementPerformance ImprovementCustomer Needs/Issues- Customer Needs/Issues- PSNPSN

What is a PSN?What is a PSN?

Patient Safety NetPatient Safety Net●● Web based method for reporting Web based method for reporting

patient safety issues.patient safety issues.● ● PSN events can be reported by all staff.PSN events can be reported by all staff.● ● Not to be used to report Staff Incidents.Not to be used to report Staff Incidents.● ● National Consortium of Hospitals utilize National Consortium of Hospitals utilize

PSN.PSN.● ● Allows hospital to track systematic Allows hospital to track systematic

issues.issues.

How do I report a Patient How do I report a Patient Safety Issue?Safety Issue?

Notify your Lead, Supervisor and/or Notify your Lead, Supervisor and/or Juanita Stem via PDS e-mail.Juanita Stem via PDS e-mail.

Include patient name, history number, Include patient name, history number, specimen number and detail of event.specimen number and detail of event.

Information will be entered into PSN.Information will be entered into PSN.

What happens to PSN What happens to PSN events?events?

• Monitored by JHH Patient Safety Committee Monitored by JHH Patient Safety Committee for trends and potential for patient harm.for trends and potential for patient harm.

• The HEAT Is ON- The HEAT Is ON- Hopkins Event Action Hopkins Event Action Team reviews PSN events weekly monitoring Team reviews PSN events weekly monitoring for trends and follow-up of PSN events.for trends and follow-up of PSN events.

• Risk Management immediately responds Risk Management immediately responds with investigations into PSN events which with investigations into PSN events which lead to patient harm. lead to patient harm.

So how does all this effect So how does all this effect Core Laboratory?Core Laboratory?

PSN Events Reported to Core LabPSN Events Reported to Core Lab July 1,05 to June 30,06 July 1,05 to June 30,06

3838 Lost/misplaced specimensLost/misplaced specimens

3232 TAT delaysTAT delays

3434 Phlebotomy issuesPhlebotomy issues

1717 Wrong/modified resultWrong/modified result

1717 Keying errorsKeying errors

1010 Customer RelationsCustomer Relations

PSN Events Reported to Core LabPSN Events Reported to Core Lab July 1,05 to June 30,06 July 1,05 to June 30,06

99 Specimen cancellation issueSpecimen cancellation issue

99 PDS/EPR issuePDS/EPR issue

88 Cancellation notification delayCancellation notification delay

66 Processing errorProcessing error

22 MiscellaneousMiscellaneous

TOTALTOTAL 1821829 9 Referred to PDSReferred to PDS

4040 No Lab Error identifiedNo Lab Error identified

PSN Events Reported by Core LabPSN Events Reported by Core Lab July 1,05 to June 30,06July 1,05 to June 30,06

• 13481348 Unlabeled/Mislabeled Unlabeled/Mislabeled • 181181 Clotted specimens for ED and Clotted specimens for ED and

NICU from April,06 to June, 06NICU from April,06 to June, 06• 1717 Timed draw issuesTimed draw issues• 4040 Patient identification missingPatient identification missing• 88 Medication misdirectedMedication misdirected• 55 Isolation Carts issuesIsolation Carts issues• 55 Pneumatic Tube delays/failuresPneumatic Tube delays/failures• 33 CAV notification information missingCAV notification information missing

• TOTAL- 1607TOTAL- 1607

What does Core Lab do with What does Core Lab do with PSNs?PSNs?

- Monitor- Monitor

- Assess- Assess

- Improve- Improve

QA MonitorsQA Monitors• Pre-analytical:Pre-analytical:

– Phlebotomy scriptingPhlebotomy scripting– AM phlebotomy completion timesAM phlebotomy completion times– Phlebotomy cancellationsPhlebotomy cancellations– Phlebotomy error ratePhlebotomy error rate– Wrist Band identificationWrist Band identification – Adult ED Hemolyzed and Clotted Adult ED Hemolyzed and Clotted

SpecimensSpecimens– NICU Clotted SpecimensNICU Clotted Specimens– Requisition EntryRequisition Entry– Requisition CompletenessRequisition Completeness– Pneumatic Tube monitorPneumatic Tube monitor

QA MonitorsQA Monitors• Analytical:Analytical:

– Antibiotic cancellationsAntibiotic cancellations– Coagulation Patient SafetyCoagulation Patient Safety– Shared urine specimen cancellationsShared urine specimen cancellations– TAT:TAT:

•Core StatsCore Stats• SuperstatsSuperstats• Adult ED LabAdult ED Lab• CCLCCL• Inpatient routinesInpatient routines• Outpatient routinesOutpatient routines

QA MonitorsQA Monitors• Post-analytical:Post-analytical:

– PDS Result ReviewPDS Result Review– Electronic Patient Record reviewElectronic Patient Record review– Tracer MethodologyTracer Methodology– CAV Read Back monitorCAV Read Back monitor– CAV TATCAV TAT

• within labwithin lab

• RN to Care ProviderRN to Care Provider

JCAHO PreparationJCAHO Preparation

•Areas of Concern:Areas of Concern:– NPSGNPSG– Proficiency TestingProficiency Testing– Electronic Patient Record Lab Electronic Patient Record Lab

ResultsResults

Name a NPSG?Name a NPSG?

• Goal 1Goal 1

• Goal 2Goal 2

• Goal 7Goal 7

• Goal 13Goal 13

National Patient Safety GoalsNational Patient Safety GoalsGoal 1Goal 1

Improve the accuracy of patient Improve the accuracy of patient identification.identification.

1A1A Use at least two patient identifiers Use at least two patient identifiers when providing care, treatment or when providing care, treatment or services.services.

1B1B Prior to the start of any invasive Prior to the start of any invasive procedure, conduct a final procedure, conduct a final

verification verification process, (such as a “time process, (such as a “time out,”) to out,”) to confirm the correct patient, confirm the correct patient, procedure procedure and site using active—and site using active—not passive—not passive—communication communication techniques.techniques.

National Patient Safety GoalsNational Patient Safety GoalsGoal 2Goal 2

Improve the effectiveness of communication Improve the effectiveness of communication among caregivers.among caregivers.2A2A For verbal or telephone orders or For verbal or telephone orders or

for telephonic reporting of for telephonic reporting of critical test critical test results, verify the results, verify the complete order or complete order or test result by test result by having the person having the person receiving the receiving the information record and information record and "read-back" "read-back" the complete order or test the complete order or test result.result.2B2B Standardize a list of abbreviations, Standardize a list of abbreviations,

acronyms, symbols, and dose acronyms, symbols, and dose designations that are not to be designations that are not to be

used used throughout the organization.throughout the organization.

National Patient Safety GoalsNational Patient Safety GoalsGoal 2, cont.Goal 2, cont.

2C2C Measure, assess and, if appropriate, Measure, assess and, if appropriate, take action to improve the take action to improve the

timeliness of reporting, and the timeliness of reporting, and the timeliness of receipt by the timeliness of receipt by the responsible responsible licensed caregiver, of licensed caregiver, of critical test critical test results and values.results and values.2E2E Implement a standardized approach Implement a standardized approach to to “hand off” communications, including “hand off” communications, including

an opportunity to ask and respond an opportunity to ask and respond to to questions.questions.

National Patient Safety GoalsNational Patient Safety GoalsGoal 7Goal 7

Reduce the risk of health care-Reduce the risk of health care-associated infections.associated infections.

7A7A Comply with current Centers for Comply with current Centers for Disease Control and Prevention Disease Control and Prevention

(CDC) (CDC) hand hygiene guidelines.hand hygiene guidelines.

7B7B Manage as sentinel events all Manage as sentinel events all identified identified cases of unanticipated cases of unanticipated death or major death or major permanent loss of permanent loss of function associated function associated with a health with a health care-associated infection.care-associated infection.

National Patient Safety GoalsNational Patient Safety GoalsGoal 13Goal 13

Encourage patients’ active Encourage patients’ active involvement in their own care as involvement in their own care as a patient safetya patient safety strategy.strategy.

13A13A Define and communicate the Define and communicate the means for patients and their means for patients and their

families to report families to report concerns about concerns about safety and safety and encourage them to do encourage them to do so.so.

Proficiency TestingProficiency Testing

What special steps are to be What special steps are to be taken when performing taken when performing

Proficiency Testing?Proficiency Testing?

Proficiency TestingProficiency Testing

• Perform PT Samples the same as Patient Perform PT Samples the same as Patient Samples:Samples:– Do not run in duplicate.Do not run in duplicate.– Do not run additional QC.Do not run additional QC.– Do not perform instrument calibration or PM.Do not perform instrument calibration or PM.– Do not select staff.Do not select staff.– Do not perform on additional instruments Do not perform on additional instruments

until after initial testing as been completed.until after initial testing as been completed.

Patient Electronic Lab Record Patient Electronic Lab Record ReviewReview

Current Department of Pathology initiative Current Department of Pathology initiative to review:to review:

• -- All current test results electronically All current test results electronically transmitted.transmitted.

• -- Any new tests.Any new tests.

• -- Any modifications to current tests, e.g.Any modifications to current tests, e.g.• Changes to reference rangeChanges to reference range

• New CAVNew CAV

• Modification to interpretationModification to interpretation

Patient Electronic Lab Record Patient Electronic Lab Record ReviewReview• Review to include:Review to include:

– Correct test nameCorrect test name– Patient identificationPatient identification– Name and address of testing labName and address of testing lab– Body source, if applicableBody source, if applicable– Collection date and time (if applicable)Collection date and time (if applicable)– Test resultTest result– Units of measurement or interpretationUnits of measurement or interpretation– CommentsComments– Finalized result date and timeFinalized result date and time– Reference rangeReference range– Results outside of reference range notedResults outside of reference range noted– CAV noted CAV noted – Laboratory identification numberLaboratory identification number

Patient Electronic Lab Record Patient Electronic Lab Record ReviewReview• Systems to be Reviewed:Systems to be Reviewed:

• 1) BDM - Pharmacy system1) BDM - Pharmacy system• 2) Compliance+ from Salar - handheld device for selected lab results used 2) Compliance+ from Salar - handheld device for selected lab results used

on Medicine floorson Medicine floors• 3) 3) EPREPR• 4) Howard County General Hospital Meditech system4) Howard County General Hospital Meditech system• 5) Bayview Medical Center Meditech system5) Bayview Medical Center Meditech system• 6) Mercury MD - (future handheld device to be used in Surgery 6) Mercury MD - (future handheld device to be used in Surgery

Department)Department)• 7) 7) OCISOCIS - Oncology system - Oncology system• 8) 8) Eclipsys SCM (POE)Eclipsys SCM (POE) - clinician order entry system - clinician order entry system • 9) QS - OB/Gyn system9) QS - OB/Gyn system• 10) 10) Eclipsys SCCEclipsys SCC - result system used in all ICU locations at the bedside - result system used in all ICU locations at the bedside• 11) Theradoc - selected lab/micro results on the Infection Control system11) Theradoc - selected lab/micro results on the Infection Control system• 12) Teleresults - (future Transplant system)12) Teleresults - (future Transplant system)

Questions???Questions???