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. The Council collaborated with the unit educator and identified distractions and interruptions as contributing factors to these errors, and they developed a process change: all lab specimens would be double-checked by another employee for the correct patient and employee labeling process before being sent to the lab. This procedure was also reinforced with education and peer training for new staff on the unit. Over the next several years, lab errors dramatically decreased to nearly zero. Due to the unit’s commitment to Just Culture, the support of leadership, and everyone’s commitment to patient safety, the risk of lab errors was greatly reduced, avoiding the discomfort of repeated tests for patients and potential delays in diagnosis and treatment.
