Sharing Knowledge: Achieving Breakthrough Performance

2010 Military Health System Conference

USAF Academy/10 MDG

26 JanuaryMs. Sandra ClarkThe Quadruple Aim: Working Together, Achieving Success

2011 Military Health System Conference

Labeling of Patient Specimens

Report Documentation Page Form ApprovedOMB No. 0704-0188

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1. REPORT DATE 26 JAN 2011 2. REPORT TYPE

3. DATES COVERED 00-00-2011 to 00-00-2011

4. TITLE AND SUBTITLE Labeling of Patient Specimens

5a. CONTRACT NUMBER

5b. GRANT NUMBER

5c. PROGRAM ELEMENT NUMBER

6. AUTHOR(S) 5d. PROJECT NUMBER

5e. TASK NUMBER

5f. WORK UNIT NUMBER

7. PERFORMING ORGANIZATION NAME(S) AND ADDRESS(ES) USAF Academy/10 MDG,4102 Pinion Dr,USAFA,CO,80840

8. PERFORMING ORGANIZATIONREPORT NUMBER

9. SPONSORING/MONITORING AGENCY NAME(S) AND ADDRESS(ES) 10. SPONSOR/MONITOR’S ACRONYM(S)

11. SPONSOR/MONITOR’S REPORT NUMBER(S)

12. DISTRIBUTION/AVAILABILITY STATEMENT Approved for public release; distribution unlimited

13. SUPPLEMENTARY NOTES presented at the 2011 Military Health System Conference, January 24-27, National Harbor, Maryland

14. ABSTRACT

15. SUBJECT TERMS

16. SECURITY CLASSIFICATION OF: 17. LIMITATION OF ABSTRACT Same as

Report (SAR)

18. NUMBEROF PAGES

13

19a. NAME OFRESPONSIBLE PERSON

a. REPORT unclassified

b. ABSTRACT unclassified

c. THIS PAGE unclassified

Standard Form 298 (Rev. 8-98) Prescribed by ANSI Std Z39-18

2011 MHS Conference

AFSO21 A3

Tum L eadu: Cl;>t Cuntr Ta.m ~lemben: !\lt. Clel.l:od (FPC), SSp Ally (A.'-JDS), SSp Kio (Dett:1), !\Is. Cl..l:d:. (PS ll.l.IJ::;qer), Ca;n A1c:iz (OR), TSp Bluemer (kt Med), SSp Colt(\1.-'HC), SSp Ellia (ACC), Mt Hayu (Histo C~1o). Facilitalon: 1\Ir P J-..att. CMSp Simmou ~'«1: M.J. RobbiCJ &: Col?'...,_, !\Is. WooU~·

1. Clarify & Validate the Probl em 0 0 D A

F rlity has identified :m increase in number of patient lab s pecimens that are unlabe:l.ed, inoorr~y labeled, or not ordered consis tent with the specimens. These specimens ha\·e come from different clinics, S differmr value streams are in place with no standard work idmtified in the facility. Trigger: Decision to obt2in specimen. End Point: L2b 2eeepts specimen..

2.

Cw, _Sut•

Break Down the Problem/ Identify @ o o A

Break Down the Problem

Perfomtance Gaps 1. The following specimm data was pro,;ded during the ~-ent_

a. An a,·erage of 6000 specimens are obt2ined per month b. Incident labeling ~ors reported on 10-15 sp«imens ~ month

(approx. 0.25% ~or rate)

):ote: It was noted during the event that the actu.al number of near miss incidmts reported monthly was low due to laboratory personnel performing rounds each morning to collect the laboratory specimens. \\"hen an ~or "'as found by the laboratory teclmici:m the specimen was left. reported to staff :md not collected until after correction, dela}''ing patient care and tre•tment.

3. Set Improvement Target o @ o A

1. 100~~ of p.atient specimens are labe:l.ed corr~y with a consis tent order flf'"st time thru the implement2tion of a standardized pr~ss for lahd cont¢'Ilt. handling specimens and ordering in all section. Sta:rt Point: decision to obtain specimens. End Point Properly labeled specimen accepted by the laboratory.

trJ ... -.-- --· ·~- ·-----

USAF A 1 OMDG Specimen Labeling

4 . Determine Root Cause 0 0 0 A

Root Cause:

5. Develop Countermeasures/ Action Plan o o @)A

Action Plan T'o9e O PR

-~· ... :.:.::::£~_:.::.=.- ~· ---·- ··-··"" - .... -..... ... ---··---- -

----- -:.:..-:.:::--::::_-::.--:::. --~-'IQO-· ~------... ----

_ .. 00. _ _ _,

c--... _ _ ,. _ __ _,_

A,. Foroo lnspecZJo n Agency

eso OCD ........

Appr-o"·al Siptatuus: Pr-oeess OwnH: ~lajor- FavHo Champion: Col Ness Event dates: 12-14 !\lay2009

6 . See Countermeasures/ Action Plan Throug h 0 0 D A 1. Team !\.1embers implement the following :

a) St2ndardize labeling pr~ss, mist2ke proof at the source b) St2ndardize label coutmt, automate with inldess printers once pr~ss

isprovm c) Place \isU2l rem.inders for providers :md support sWf_

2. Event countermeasures ,,·ere presented :md approved by the 10 !\.IDG Exocutin St2ff 21 M ay 20 10.

3. CPI - 15 July 2009 no ch.:mge in results -found new ~sonnet were not r~'ing the training. All clinics added training to D~'·comers unit training. Roponed as completed to E.xocum·e St2ff 28 Aug 09.

7 . Conf"lflll Results & Process 0 0 0 A

1. P S 1\l.IJ::;qer 9-"ill ua:k a:cd ""';~- sptcime:c: J:Ut ciu.iccide:.t ApOSt oor.tbly. ,---L"'-'Em.ai"" •t moz:.tblv a~· tO cli:cia for,..;~· and loll~· U ~

Mislabeled/Ordered Specimens 16

12 10

• . 2

0 I I . I I I I I I • • • •

Numbeot'or ~pecunen~

m·~••~lt!'d

/ Otde-tt!'d P4H"month

a. BrMl."tl:ro\.:.,Jh Joal .td:.i...,w! Oct 09. •z-o Dd.a !\I.IJ::..q:er:ne::.t in PfOJR:U-b . Foad uai.r.ir.J ofew.· st.affr.ot ;un o f ode::.tmio~ to clicic orie::.tation cbtcl:list c. ~ Jip:;q:e rot in appropria:e .aru.s pon o O'\-..di.cia ft'\."isit~ & ~fd: 0r1

e+td 'pl.;:tpos.t !or \<"iS\W. o,:.es d.. Confi.a::1.S ir.l:l.u prieter:s r.ot ~-od:ie& ~cely r.or cocaaed i.e. all d.icia.­Sy s tts::U ~tacted clil:ic NCOIC O ICJ &: pta.::.d. cor.:;.eaed u .trppfOprict e. PfO""i6ed rm:ai.ci.r.J to all cli.cic POCa, con6.a::1ed sud!' ~1edJ• of prieter:s c:.d rti"':::dfd: clitia to cor..5n:l placer::1mt o f ""isual a:-a f. Dr. -.loped s~ label v."ith Systecu !or use on all apecic.cu, ~;th rooc to hc::d prir.t E). c:.t:.Sl::al peni.z:..e::.t icJon::u:tion.

8. Standardize Successful Processes 0 0 D A

1. Rewrote the ~IDGI ECD post-swt2inm.m t. 2. Loggl!d ., . ..,t into CPI-1\IT updato as rosults aro .,-:oilablo. 3. Contact SAF SO for AF integration if countermeasure result if significant

f------------------------------------------------------t+ l impro,·ement occurs .

~---------------------------------------------------------------------------------------------------------------------------------- ---r--------------. ,:_start,. ~~ ~afmoa·A·3FMEALab ... rm~ ~EI r<,.J_•te ! 2 :46PM

2011 MHS Conference

1. Clarify/Validate the Problem-OODA

Assure all Understand Same Issues:Facility has identified an increase in number of patient lab specimens that are unlabeled, incorrectly labeled, or not ordered consistent with the specimens. These specimens have come from different clinics; 8 different value streams are in place with no standard work identified in the facility. Trigger: Decision to obtain specimen. End Point: Lab accepts specimen.

2011 MHS Conference

Break Down the Problem Performance Gaps:

1. The following specimen data was provided during the event.

a. An average of 6000 specimens are obtained per month

b. Incident labeling errors reported on 10-15 specimens per month (approx. 0.25% error rate)

2. Break Down the Problem/Identify-OODA

2011 MHS Conference

3. Set Improvement Target-OODA

Identify Target1. 100% of patient specimens are labeled correctly with a consistent order first time thru the implementation of a standardized process for label content, handling specimens and ordering in all section.

2011 MHS Conference

4. Determine Root Cause-OODA

Sponsor

Fish bone Diagram

Order/Label mismatch

Specimen not labeled expeditiously

Doesn't prep room

Multi tasked

Computer

Don't know sponsor info.

Don't update data (records)

Parent mixes up child-en data

Don't comm. w/tech there is spec.

Create eligible label

Inconsistent handing of spec

Multiple spec site in the container

Order/label mismatch

Training Uniform Standard

Air Force Inspection Agency

U.S. AIR FORCE

2011 MHS Conference

5. Develop Countermeasures & Action Plans- OODA

Action Plan Descri~tion ~ OPR

Develop Standard Process to label specimens .Just Do It Capt Alaniz Lab and Path processes (support staff -double check order (.JDI)

before sent to lab, only handle specimens (assigned), ask patient for name, DOB, last 4 SSN, ensure specimens never leaves label and if moved it is labeled), All orders in system and all near misses and errors reported to patient safety

Purchase/Install printers in each clinic to print labels .JDI Capt Cutter

Research compatible printer, Cost, Time Frame

Develop standard training for all clinics .JDI SSgt Ally

Develop standard label content for all clinics .JDI MrHaynes

Develop Visual Management Sheets SSgt Cole

For Providers, support staff (reminders) .JDI SSgt Ellis

Steps at computer for labeling (exit doors in clinics)

Develop labeling instruction for all Clinics

Attachment to MDGI 44-10 Project SSgt Kim

Notify change to clinic orientation checklist

Team members meet 1/41y for feedback and review results Ongoing Maj Favero Meeting 14 Aug 09, 1400 in lab break room thru out

Develop TICK sheet to track near misses .JDI Ms. Clark

Clinics will provide toPS 1st working day of month

Air Force Inspection Agency

ESD

14 May 09

14 May 09

15 May 09

14 May 09

14 May 09

15 May 09

14 Aug 09

15 May 09

~J ••• • ECD

14 May 09

22 May 09

(proposal)

29 May 09

15 May 09

19 May 09

5 .June 09

Aug 10

19 May 09

(sheet)

2011 MHS Conference

6. See Countermeasures/Action Plan Through- OODAFollow Through:

1. Team Members implement the following:a. Standardize labeling process, mistake proof at the sourceb . Standardize label content, automate with inkless printers

once process is provenc . Place visual reminders for providers and support staff

2. Event countermeasures were presented/approved by the 10 MDG Executive Staff 21 May 2010 3. 15 July 2009 no change in results - new personnel not receiving training. Added to clinic unit orientation. Reported as completed to Executive Staff 28 Aug 09.

2011 MHS Conference

7. Confirm Results & Process-OODA

Tracking & Trending:1. PS Manager will track and review specimen near

miss/incident report monthly.a. Email monthly summary to clinics for review and follow-up as needed.

2011 MHS Conference

8. Standardize Successful Processes-OODA

Standardization:1. Rewrote MDGI ECD post-sustainment2. Updated event into CPI-MT as results available3. Contacted SAF/SO for AF integration of

countermeasure result w/ significant improvementLessons learned:

1. Need for active patient involvement-assure accuracy of their information: Patients are KEY!

2. Standardized work is essential: Visual Cues3. Visual Cues decrease risk.

2011 MHS Conference

Visual Cue #1 In Exam Rooms

SPECIMEN COLLECTION & LABELING Visual Reminder

- ACTIVE QUESTIONING USED? ( A s k the PT to state name, DOB, & spon sor's last four)

- STANDARD LABEL COMPLETED AND INITIALED? (Staff member and PT verify label * & initial)

D001 O l J UL. 1 '9'92

'9'9/'9'9'9'9

DA Til/Tt ,..U: •------8 0UACt!t1

- SPECIMEN COLLECTED AND IN CONTAINER?

- APPLY LABEL TO THE SPECIMEN CONTAINER ( IN P ATIENT'S PRESENCE WHEN POSSIBLE)

- SPECIMEN ORDER IN SYSTEM - Pathology in CHCSt

- lab in e ither AH l TA or CHCSt

- VERIFY LABEL ON SPECIMEN WITH ORDER IN SYSTEM*

- TAKE SPECIMEN TO PATHOLOGY/ LAB

- NOTIFY PATHOLOGY/ LAB OF ANY VARIANCES THAT CANNOT BE CHANGED

* CORRECT ANY ERRORS DOCUMENT FINDINGS ON TICK SHEET

2011 MHS Conference

Locate the slide containing the video and right click on it. Click on EDIT MOVIE OBJECT Click on the “SOUND VOLUME” button and adjust as

necessary Click OK when finished

Visual Cue #2 At Provider’s Desk

2011 MHS Conference

Visual Cue #3 Clinic Specimen Room Exit Door

ARE THOSE SPECilVIENS ORDERED???

DO THOSE SPECilVIEN LABELS MATCH THE ORDER???