When a nurse coordinator found out that lab orders could be faxed directly from the Epic electronic health record system, rather than needing to be printed and faxing a hard copy to lab facilities, she decided to test the functionality to make sure it worked correctly and accurately.
Staff in a busy, 30-bed geriatric unit at a community hospital escalated errors to their unit’s practice Council for event review. The Council’s investigation revealed system issues, particularly regarding lab orders, which were shared with leadership; for example, specimens being sent to the lab without required employee identifiers and the wrong patient label.
Laboratory leadership embracing a culture of transparency and safety at their hospital—encouraging reporting through positive recognition of staff and continuous process improvement to mitigate operational risks—has increased reporting and resulted in positive changes to keep patients safe.