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Course Instructions
Please proceed through the course by clicking on the blue arrows or text links. Use the table of contents to monitor your progress. Your progress will be saved automatically as you proceed through the course, and you may later continue where you left off even if you use a different computer. You may encounter practice questions within the course, which are not graded or recorded.
Course Info
This course carries the following continuing education credits:
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P.A.C.E. Contact Hours: 2.00 hour(s) Course Number: 578-012-11 Florida Board of Clinical Laboratory Science CE - Medical Errors: 2.00 hour(s)
Six aims of the Institute of Medcine (IOM) to improve health care quality.
Six aims of the Institute of Medcine (IOM) to improve health care quality.
Six aims of the Institute of Medcine (IOM) to improve health care quality.
1. Health care that is safe "avoids injuries to patients from the care that is intended to help them."* Patients should not be harmed while receiving health care from events such as nosocomial infections, missed diagnosis, or other iatrogenic sequelae resulting from interaction with any aspect of the health care system. 2. Effective health care provides services based upon scientific knowledge to those who would benefit from that care and refrains from providing care to those who are not likely to benefit. Health care that is effective avoids underuse and overuse of services. 3. Patient-centered health care is care that is delivered in a manner that is "respectful of and responsive to individual's preferences, needs, and values." The principle of this aim is that it is patients' values that guide all clinical decisions, not those of the health care provider. 4. Health care that is timely "reduces waits and harmful delays for those who receive and those who provide care." Patients should receive care at the time when it would be most helpful in identifying the cause of their condition, followed by receiving interventions needed to treat those conditions. 5. Health care that is efficient avoids waste. This includes waste of equipment, supplies, ideas, energy and time, for both patients and health care practitioners. 6. Heath care that is equitable "does not vary in quality because of attributes such as gender, ethnicity, geographic location and socioeconomic status." *Reference: Committee on Quality of Health Care in America. Crossing the Quality Chasm, A New Health System for the 21st Century. Washington, DC: National Academy Press. 2001.
Six aims of the Institute of Medcine (IOM) to improve health care quality.
Improving Effectiveness
Problems in health care quality have focused upon medical errors--harm to patients that resulted due to experiences with the health care system. However, safety--doing no harm; is only one aspect of the broad term that "patient safety" encompasses. Because the IOM has defined health care quality as "The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge," its six aims include more than avoiding or reducing harm in the health care delivery process. Health care that is effective is one that does not perform more tests than necessary to diagnose and treat patients' conditions, yet appropriate and adequate tests are performed in order to diagnose and treat conditions in a timely manner. Scientific evidence is critical to identify appropriate tests and treatments so that overutilization, underutilization and misutilization of health care processes is limited.
Six aims of the Institute of Medcine (IOM) to improve health care quality.
Coordinating the services patients receive Communicating in a manner that patients understand Alleviating anxiety Reducing patients' pain Involving patients' family members in decision making if they have the role of caregivers
Timeliness is critical throughout the entire health care delivery process--beginning with time waiting on hold to make an appointment or to speak to a clinician, to waiting for an appointment, and receiving results of diagnostic procedures. Health care practitioners experience similar waiting during the course of delivering care to their patients.
Six aims of the Institute of Medcine (IOM) to improve health care quality.
Pay attention to the care they receive; making sure they receive the right treatments. Educate themselves about their diagnosis, medical tests, and treatment plans. Ask a trusted family member or friend to be their advocate when they cannot "speak up" for themselves. Know their medications and why they take them. Choose hospitals, clinics, surgery centers, and other health care organizations that undergo rigorous onsite evaluation. Participate in all decisions about their health care and treatment.
Reference: Speak up: Help prevent errors in your care. Joint Commission website. Available at: http://www.jointcommission.org/topics/speakup_brochures.aspx. Click on "Topics" then "Speak Up." Accessed November 14, 2013.
Six aims of the Institute of Medcine (IOM) to improve health care quality.
such as using information systems; or it can be improved by limiting the amount of rework that is performed by addressing each situation as it arises. The role of equity in the health care delivery system is to improve the health of the entire population and to provide that care without discrimination. The quality of care delivered to each individual should not vary due to personal characteristics such as gender, geographic location, and socioeconomic status.
Six aims of the Institute of Medcine (IOM) to improve health care quality.
Six aims of the Institute of Medcine (IOM) to improve health care quality.
c Timely d e f g c Patient-centered d e f g c Physician-centered d e f g Feedback According to the IOM, health care systems of the 21st century should strive to be safe, effective, patient-centered, timely, efficient and equitable.
IOM aims within the context of quality clinical laboratory services. How might patient harm result from each of these problems related to clinical laboratory services? Consider your answer and then click on the defined problem to reveal the potentially harmful result(s) of the action or condition. False-positive (laboratory test result is reported as positive when it is really negative) or false-negative test result (laboratory test result is reported as negative when it is really positive).
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IOM aims within the context of quality clinical laboratory services. How might patient harm result from each of these problems related to clinical laboratory services? Consider your answer and then click on the defined problem to reveal the potentially harmful result(s) of the action or condition. False-positive (laboratory test result is reported as positive when it is really negative) or false-negative test result (laboratory test result is reported as negative when it is really positive). Increased turnaround time Inappropriately performed venipuncture or skin puncture
Feedback
Measuring timeliness of clinical laboratory services is ingrained in medical laboratorians. Timeliness needs to be expanded to encompass more than the portion of the total testing process that occurs within the walls of the clinical laboratory. For example, a more accurate description of timeliness begins with the time from test order entry and also identifies how long it routinely takes for action to be taken after test results are sent to a clinician.
Recognizing problems (errors) that could occur in each phase of the total testing process
Medical Errors
Medical errors are mistakes medical professionals make in patient testing, care, or treatment. Categories of medical errors include:
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Failures of planned actions Mistakes of execution Use of wrong plans to achieve outcomes
There are two types of medical errors: Errors of commission Errors of omission Errors of commission are medical errors involving wrong actions. Mislabeling a test specimen, drawing a blood sample from the wrong patient, or incubating a test at an incorrect temperature are all errors of commission. Errors of omission are medical errors that occur when an individual fails to act. In the laboratory setting, errors of omission include such things as omitting a reagent in a test, failing to communicate a critical test result, failing to collect a timed test sample at the correct time.
Recognizing problems (errors) that could occur in each phase of the total testing process Factors that Contribute to Medical Errors Multi-tasking Automatic actions (automaticity) Suboptimal work environment
Recognizing problems (errors) that could occur in each phase of the total testing process Factors that Contribute to Medical Errors Multi-tasking Automatic actions (automaticity) Suboptimal work environment
Feedback
Recognizing problems (errors) that could occur in each phase of the total testing process
Recognizing problems (errors) that could occur in each phase of the total testing process
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Patient preparation H Patient not told to be fasting H Improper or no instruction to patient on proper collection of specimen such as clean catch urine Patient injured during phlebotomy H Development of hematoma H Nerve or tissue damage caused by improper technique or wrong-site venipuncture Requisition errors H Patient information missing, illegible, or on wrong patient H Wrong tests ordered Patient identification H Patient incorrectly identified H Specimen not labeled or incorrectly labeled Specimen integrity H Not enough specimen for testing H Visible hemolysis H Inadequate cleansing of venipuncture site resulting in contamination during blood culture collection H Specimen centrifuged too long or not long enough H Specimen placed in improper preservative H Specimen transported at the wrong temperature (eg, specimen that should be placed on ice immediately after collection is transported at ambient temperature) Shipment of specimen H Shipped at ambient temperature when it should have been shipped frozen H Delay in shipment Order entry H Incorrect data entered during manual entry of a test requisition
*Reference: Bonini P, Plebani M, Ceriotti F, Rubboli F. Errors in laboratory medicine. Clin Chem. 2002;48:691-698. Available at: http://www.clinchem.org/cgi/content/full/48/5/691#T2B. Accessed November 19, 2013.
Recognizing problems (errors) that could occur in each phase of the total testing process
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Instrument malfunctions Calibration errors causing a direction of bias in results Manual pipetting errors Reagent errors Specimen interference (eg, lipemia or hemolysis) Calculation errors Inadequate staffing which may precipitate errors caused by fatigue
Recognizing problems (errors) that could occur in each phase of the total testing process
G G G G G G
Laboratory results not verified before being reported. Improper data entry or typing mistakes causing erroneous information to be reported Critical values not reported, or not reported in a timely manner Laboratory tests not reported or reported to the wrong health provider (For example, poor communication to a patient's physician of the results of laboratory tests that are pending at the time of a patient's discharge) Lack of timeliness of reporting laboratory results (slow turnaround time) Misinterpretation of an alphabetic flag in the result field (eg, lower case "l" interpreted as the number "1") Oral results misunderstood by receiving party- no "read back" requested to confirm that data was correctly received Abnormal test not recognized by the clinician Failure of clinician to order appropriate follow-up testing Failure of clinician to communicate test results and next steps to patient and family
In the postanalytic phase, the test result becomes information that the clinician must act upon. The test information and the action have an effect on the patient--either to benefit or harm the patient's health. Tracking what occurs after laboratory test results are sent to clinicians is a new concept for clinical laboratorians. However, this mindset is important to truly measure the safety of clinical laboratory services.
Recognizing problems (errors) that could occur in each phase of the total testing process
For patients to ask questions To share information that is important to the sample collection process To describe post-venipuncture self-care information.
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Recognizing problems (errors) that could occur in each phase of the total testing process
Recognizing problems (errors) that could occur in each phase of the total testing process
Recognizing problems (errors) that could occur in each phase of the total testing process
Recognizing problems (errors) that could occur in each phase of the total testing process
Recognizing problems (errors) that could occur in each phase of the total testing process
Recognizing problems (errors) that could occur in each phase of the total testing process
Choose Choose
6 Preanalytic 6 Preanalytic
Feedback Preanalytic- Incorrecly collected sample, wrong test ordered, incorrectly performed venipuncture Analytic- Incorrectly performed instrument calibration Postanalytic- Incorrectly handled critical test value
Living Getting well Improving health and function Being cured Receiving a proper diagnosis Going into remission Receiving a treatment or medication adjustment Being discharged from the hospital
Inappropriate medical treatment Inappropriate medication adjustment Incorrect diagnosis Delayed diagnosis Delayed treatment
All of these negative outcomes require investigation. An unexpected event that has resulted in death or serious injury (physical or psychological) or an event that was averted, but may have resulted in death or serious injury (often referred to as a "near miss") must be investigated by performing a root cause analysis.
Reporting of Errors
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A near miss should be handled non-punitively, if possible. One reason is so that personnel will freely report these occurrences without fear of being punished or fired. Another reason is that a process problem is usually due to either a process flaw or a managerial error. Perhaps sufficient safeguards are not in place to prevent an error, or perhaps personnel are not being assessed for the competencies they need to perform the job safely. An environment of blame encourages a culture of secrecy about medical mistakes. Mandatory reporting laws have not overcome this secrecy, and they do not encourage efforts to find ways of avoiding errors. Error reduction requires a commitment from the community to recognize and acknowledge that medical errors most often indicate systems problems, not people problems.
One of the tools that can be used when performing a root cause analysis is the cause-andeffect diagram, which is often referred to as a "fishbone diagram" because of its appearance. Cause-and-Effect (Fishbone) Diagram Example This type of diagram graphically helps identify and organize known or possible causes for a specific problem or area of concern. In this theoretical example, the identified problem is a "near miss." Two units of RBCs were taken to the Dialysis unit for tranfusion of two different patients. The first unit was hung by one clinical person and started just as another clinical person noticed that the unit that he/she picked up for transfusing another patient had the wrong identifying information. The blood was stopped immediately on the first patient. Some of the benefits of constructing a "fishbone diagram" are that it:
G G G G
Helps determine root causes using a structured approach. Encourages group participation and utilizes group knowledge. Indicates possible variations in a process. Indicates areas where more data should possibly be collected.
The Joint Commission National Patient Safety Goals 2014 for Clinical Laboratories
The Joint Commission is an independent agency that accredits health care organizations and programs. Since 2001, the Joint Commission has published Patient Safety Goals with the intent of reducing medical/health care errors by focusing on patient safety issues. The Joint Commission National Patient Safety Goals, effective January 1, 2014, that apply to clinical laboratories are:
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Use at least two patient identifiers when providing laboratory services. Report critical results of tests and diagnostic procedures on a timely basis to the right person. Comply with either the current Centers for Disease Control and Prevention (CDC) hand hygiene guidelines or the current World Health Organization (WHO) hand hygiene guidelines. Set goals for improving hand hygiene procedures.
These are not new goals for the laboratory to follow. Patient identification procedures and communication of laboratory test results were included in the first list of goals in 2003. Reducing health care-associated infections has been a goal since 2004. Reference: The Joint Commission National Patient Safety Goals.
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Individual's full name An individual-specific identifier, such as H birth date H hospital number H medical record number H other assigned unique identification number
If a patient is able to respond, it is also important to ask the patient to state his or her name. Specimens must be labeled in the presence of the patient.
Please select the single best answer j Patient's complete name k l m n j Birth date k l m n j Hospital identification number k l m n j Patient's room number k l m n Feedback Patient's location in the hospital is not a unique identifier. A patient's full name, birthdate, and hospital identification number are all acceptable forms of patient identification. However, remember that at least two forms of identification are needed. For an outpatient, name and birthdate could be used. For an inpatient who has a unique hospital or medical record number, it is best to use this number also as a positive identifier.
Conclusion
References
References
Barr JT, Schumacher GE. Outcomes Assessment of Therapeutic Drug Monitoring: System and Patient Considerations in Schumacher GE. Therapeutic Drug Monitoring. Norwalk, CT: Appleton & Lange 1995, pp. 191-236.
Clinical and Laboratory Standards Institute (CLSI). Continual Improvement; Approved Guideline. 3rd ed. CLSI document QMS06-A3. CLSI. Wayne, PA: 2011. Clinical and Laboratory Standards Institute (CLSI). Quality Management System: A Model for Laboratory Services; Approved Guideline. 4th ed. CLSI document QMS01-A4. CLSI. Wayne, PA: 2011.
Committee on Quality of Health Care in America. To Err is Human, Building a Safer Health System. Washington, DC: National Academy Press. 2000. Committee on Quality of Health Care in America. Crossing the Quality Chasm, A New Health System for the 21st Century. Washington, DC: National Academy Press. 2001. Hand hygiene basics. The Centers for Disease Control and Prevention. Available at: http://www.cdc.gov/handhygiene/Basics.html. Accessed November 19, 2013. McDowell I, Newell C. General Health Status and Quality of Life in McDowell I, Newell C. Measuring Health, A Guide to Rating Scales and Questionnaires. New York: Oxford University Presss. 1996, pp.380-492. The Joint Commission National Patient Safety Goals. http://www.jointcommission.org/standards_information/npsgs.aspx Accessed November 19, 2013.