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. Lab staff enter an average of 10 events daily into the safety event reporting system, and lab technologists reported 33% of all events hospitalwide in fiscal year 2018. Among these are events in which lab staff were unable to reach the provider caring for a patient with a critical lab value. Trending these, they discovered that the wrong phone book had been loaded into the electronic health record (EHR) when it was rolled out. Later, their reporting also uncovered that advanced practice providers had office numbers rather than cell phones in the system. After the systemic problems were fixed, lab reporting identified individual providers who were failing to sign in or out of the EHR as the provider covering the patient. Over time, these efforts have dramatically reduced the frequency of this type of event. Recently, lab staff have begun auditing charts for documentation that providers have been notified of critical values from point-of-care tests performed by bedside staff. These reports will make the case for a new process improvement project to improve such documentation.
Trending of rejected specimen reports revealed an extremely high rate of rejection in the intensive care nursery. A project was created to investigate, which resulted in a separate set of rejection parameters was created for neonatal specimens. Rejected specimen reporting also led to development of a new competency program for all bedside nurses and techs regarding proper specimen containers, drawing technique, and specimen handling. Lab staff also report their own errors, including improperly running a test on a clotted specimen, running the wrong test, misreading a slide, failure to call a critical result, and any corrections of initial results.
