PA PSRS Patient Saf Advis 2007 Jun;4(2):63.
Going Beyond the Simple Fix

Here is an example of one Pennsylvania facility’s in-depth efforts to resolve a patient safety problem. Butler Health System submitted the following report to PA-PSRS: 

An experienced laboratory technician interpreted a control slide as a patient slide. She reported that a patient’s synovial fluid contained gram-positive organisms, but the correct result was no organisms. The laboratory technician then recognized the error and contacted the nurse and orthopedic surgeon. The patient was in the operating room under anesthesia. Fortunately, the correct result was reported before the surgical procedure  was started. 

The facility’s investigation revealed that both the control slides and patient slides were identical in design — plain, clear, non-distinct glass. While the technicians initialed and dated control slides, it was not their practice to document on the slide its control status. Moreover, at the time of this occurrence, no procedure existed to differentiate between control slides and patient slides. Although there was a procedure to monitor for misreads, this monitoring ordinarily occurred the following day. 

As a result of this occurrence, the facility purchased a new type of control slide that was frosted at one end. This slide is used solely for gram stain controls. In addition, the facility implemented a new procedure requiring staff to write “GS” on the slide to indicate that it is a gram stain control. 

While, on the surface, these changes might appear to fix the problem, the facility dug deeper to uncover underlying issues that contributed to this occurrence. One system breakdown identified was distraction in the workplace. The facility implemented a process in which technicians place an orange caution sign at their work stations to prevent others from interrupting them while they are performing readings. The employees were educated about the new slides and processes. 

The technician involved in this occurrence was distraught about the event. The facility offered support and counseling, and reinforced the fact that her timely reporting of this error prevented unnecessary surgery and further patient harm. 

Finally, the facility revised its misreads protocol to heighten awareness to all laboratory staff involved. All laboratory employees receive the following information: misreads divided by the total number of reads per employee (deidentified). Moreover, the manager provides each individual with his/her rate of misreads on an ongoing basis. This information is used as a springboard for the healthcare team to identify, together, further systems or process breakdowns and oppor-tunities for patient safety improvement.  For more information about how Butler Health System responded to this issue, contact 724-284-4862.


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