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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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Aims of the Institute of Medicine
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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Aims of the Institute of Medicine
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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Safe: measures of deficiencies
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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Safe: measures of deficiencies
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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Improving measurement of timeliness
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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Improving measurement of timeliness
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
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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.
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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
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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 out- patient
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
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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
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Contact Information
Catherine Otto, PhD, MBA, MLS
mailto:[email protected]:[email protected]