A patient came to a neurologist’s office with unusual symptoms requiring further testing. The neurologist ordered a lumbar puncture (spinal tap) to obtain cerebrospinal fluid (CSF) for testing and completed a paper CSF prioritization worksheet to communicate with the lab which tests were most critical, in case there was not enough CSF for every test. The paper form was sent to the lab with the CSF specimen after it was collected, but later it became evident that some required tests were missed because the neurologist had added more tests through the electronic medical record but did not update the prioritization worksheet. As a result, the patient needed to return for a repeat lumbar puncture so that more fluid could be obtained.
The radiology nurse who worked with CSF patients recognized that the need to not only simplify the process, but also standardize it and enhance communication across the network. She raised her concerns and made others aware of the problem by using the patient safety event reporting system and communicating with the neurologists, lab and other radiology nurses. A multidisciplinary team was formed to improve the CSF ordering workflow to avoid future safety issues and ensure that no patient would have to undergo an unnecessary repeat invasive procedure. The team developed an electronic process that allows the physician to enter all the orders and notify the lab of what tests are most critical. Since this implementation, there have been no unnecessary repeat lumbar punctures for patients—the right tests are ordered for the right patient and completed in the right order, the first time.
