Categories
Thumbnail associated with Event Reporting story titled: Code Blood Bank
Code Blood Bank
Emergency Department
Communication
Lab
In response to an emergent blood transfusion scenario, emergency department (ED) staff followed policy and contacted the blood bank to start the unmatched blood acquisition process in case rapid transfusion was needed. However, once the order was received, the blood bank encountered several barriers to complete the request.
Thumbnail associated with Event Reporting story titled: System Malfunction Results in Incomplete Lab Orders
System Malfunction Results in Incomplete Lab Orders
Electronic Health Record
Lab
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.
Thumbnail associated with Event Reporting story titled: Reducing the Risk of Lab Errors
Reducing the Risk of Lab Errors
Lab
Nursing
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.
Thumbnail associated with Event Reporting story titled: Building a Safety Culture and Encouraging Reporting
Building a Safety Culture and Encouraging Reporting
Electronic Health Record
Equipment
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.