College of American Pathologists
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  Patient safety errors on the CHOPing block


CAP Today




May 2011
Feature Story

Anne Ford

Patient-safety champions sometimes pop up from unexpected places. And when they do, the results are potentially lifesaving. Just ask microbiology supervisor Deborah Blecker-Shelly, MS, MT (ASCP)SM, of Children’s Hospital of Philadelphia.

“About a year ago, an environmental services staff member [at CHOP] was asked to change a patient room from negative to positive air pressure,” she recalls. “Yet he knew that the patient was on respiratory precautions. He persisted—despite some uncomfortable conversations with clinical staff who insisted he convert the pressure—until he received support from a supervisor, who confirmed that the pressure should remain negative.”

The incident illustrates an exciting trend at CHOP: a growing sense of responsibility for patient safety among all staff, not just those on the frontlines of care, says Deborah Sesok-Pizzini, MD, MBA, CHOP’s medical director for blood bank and transfusion medicine and associate professor of clinical pathology and laboratory medicine, University of Pennsylvania School of Medicine.

“That speaks to the overall cultural transformation that’s going on at CHOP for patient safety,” she says. It’s the hospital’s patient safety officers, of which Dr. Sesok-Pizzini is one, who have been formally tasked with maximizing safety. But in an effort to meet its stated goal of becoming the safest pediatric hospital in the country by 2015, CHOP is enlisting the support of all employees, whether they happen to be pediatricians or information technologists.

That’s where Blecker-Shelly, Ashley Lebria, MT(ASCP), Brooke Allen, MT(ASCP), and Charles Sansone, MT(ASCP), have come in. In the past year, these four CHOP laboratorians have launched a series of tours designed to help non-laboratorians (clinical or otherwise) understand what goes on in the hospital’s laboratories, and how staff interactions with the laboratories can affect patient safety. Blecker-Shelly is executive lead of the new Lab Awareness Program.

If a laboratory tour sounds like too frou-frou an intervention to have any real effect, consider these numbers: In the year since the tours have been implemented, the rate of molecular tests from the emergency department for Chlamydia and gonorrhea that have been canceled due to improperly collected specimens has dropped by 77 percent. And, Sansone says, the rate of clotted blood specimens that have been found to be inadequate for blood gas analysis and therefore resulting in test cancellation has dropped by 73 percent. These improvements are a direct result of the lab having introduced the tour program as an add-on to existing in-servicing activities, says Blecker-Shelly.

How has a simple tour been able to produce such dramatic results? For one, a tour allows laboratorians to stop telling medical staff what’s wrong with some of the specimens they submit, and start showing them instead. “Some of the labs are able to do show-and-tell—doing gram stains under the microscope” and such, says Lebria, who works in the microbiology laboratory. For another, there’s something about having a real live laboratorian hold up a gray-top urine tube, point out the minimum fill line, and explain why it’s important that helps the message sink in.

“Those tubes have a preservative in the bottom. Sometimes they’re not filled to the minimum fill line, and we have to cancel the test because the ratio of sample to preservative is off,” Lebria says. “That’s one of the main things I try to go over when nurses tour the lab. They realize the tube has a minimum fill, but they don’t understand the importance of filling it.”

Then, too, “we’re only allowed to receive fluids and tissue specimens for AFB testing,” Lebria continues. “Sometimes the OR will try to submit a swab, and that’s unacceptable. Those are the types of things we try to push through on tours. Submitting specimens properly eliminates the phone call to clarify an issue, and it allows the person on the bench to stay focused on the processing.”

“By minimizing phone calls, we’re optimizing patient safety,” says Allen, who works in the clinical virology laboratory. “Any time there’s a disruption like that, it takes the nurse or technologist away from their job responsibilities and potentially increases the chance for error.” Since tours of the virology laboratory have become available, she’s seen a drop in the number of calls from nurses asking when the results of rapid respiratory viral PCR panels will be available. “When we try to show them briefly the steps that are required, they realize that it’s not really a rapid test; it’s a six- to 10-hour test, potentially. It’s one of the most rapid methods out there, but it’s not as rapid as they think it is. So we’ve seen a decrease in the number of calls asking when it’s going to be resulted.”

Another positive development: “We have seen an improvement in labeling,” she says. “In virology, we weren’t necessarily getting mislabeled specimens, but we were getting samples without a collection time on them, or without the collector’s name. By bringing nursing staff into the lab, we have definitely seen an improvement in samples labeled correctly.”

That’s especially helpful for samples the emergency room sends. “Virology is not a 24-hour lab,” Allen points out. “So samples collected when we are closed are held in our central lab, and an incorrectly collected sample is not canceled until we arrive the next day, when the patient is most likely no longer in the ER. These cancellations directly affect the patient due to a delay in testing, delay in diagnosis, and the inconvenience of having the patient return to give another sample.” That’s why, on tours of the virology lab, “we show the nurses an incorrectly and correctly collected sample and give an explanation. We also explain the potential for false-negative results due to improper collection. Seeing it really makes it sink in.”

Ten laboratory tours are now available at CHOP: microbiology, virology, phlebotomy, immunology, molecular genetics, anatomic pathology/cytology, blood bank, central laboratory services, core lab hematology/coagulation, and core lab chemistry/ICU blood gas lab. A tour of the metabolic laboratory is expected to be added soon. On many of the tours, participants receive specimen collection cards that offer “reminders about minimum fills, what your backup method should be,” and the like, Lebria says, so that if they have a question while collecting a specimen, “they can pull the information card out from their pocket or their notebook rather than having to leave the patient.”

The tours are not meant to be punitive affairs conducted in a “let’s show you what you’re doing wrong” spirit. “We’re not trying to be judgmental,” Dr. Sesok-Pizzini says. “The intent is to say: ‘Thanks so much for coming, and here’s how you can help us take care of patients better in the future.’” “For the most part,” Lebria adds, “the individuals who come through on the tours have requested the tours themselves. They’re enthusiastic and look forward to them.”

Allen and the other technologists who coordinate the tours try to foster a relationship with the nurses and other tour-takers ahead of time. She says: “We have a dialogue with them over e-mail or over the phone before they come in, and having that takes away some of the potential edginess or discomfort. We already know their names; they already know our names.”

A nurse who has taken several laboratory tours at CHOP attests to their strictly educational nature. “We all were given an opportunity to sign up for a lab tour if we were interested, and a bunch of us did sign up. I actually found it fascinating,” says ER nurse Emily Glickman, RN, BSN, who has toured the microbiology, blood gas, chemistry, and hematology laboratories. “For certain lab tests that we always get a little ding on, such as urine cultures, I was able to see that if there’s really not enough [sample], it can’t be read, because it’s measured by a certain tool. Being able to see how they measure the sedimentation rate and why they need the amount they do in the tube helped clarify things for me and many others in the ED.”

And one of the items that’s been clarified, says microbiology supervisor Blecker-Shelly, is the importance of the medical technologists’ role. Before the tours were implemented, “the nursing staff really wasn’t aware of the depth of education on the technologists’ side,” she says. “One of the well-known feelings among clinical laboratory scientists—and this is certainly true in our organization—is that they feel a lack of respect outside the laboratory department. By having folks come in for tours, it gave them a chance to understand the level of skill and education that the technologists possess. I think that’s helped support a general sense of increased respect,” always a valuable factor in job satisfaction and staff retention.

Even nonclinical staff have benefited from the tours, Blecker-Shelly says. “One of the most valuable tour experiences was having the information systems team come through about a month before we went live with a new inpatient information system,” she says. “It gave the technologists a chance to discuss concerns about problems we had with the system and feedback about what needed to be in place during the go-live weekend. You wouldn’t necessarily think that the laboratory staff would need to partner with the information systems people for optimal patient care, but there was a really good exchange.”

Other nonclinical staff who have taken advantage of the tours have come from CHOP’s environmental services, clinical trials, finance, and client service departments. The tours offer something relevant to each of them, Blecker-Shelly says. For example, she reports, “Finance staff were able to learn that decreased numbers of test orders for blood cultures reflected one of the organization’s patient safety initiatives for reduction of central-line-associated bloodstream infections. And for environmental services staff, improvements to patient safety could come from learning about infection-control-related issues, proper biohazard waste disposal, hand washing, et cetera.”

Even laboratory staff themselves can benefit from touring labs other than the one they work in. “Sometimes when you work in a large lab and not all in the same buildings, you work in silos, and it’s hard to appreciate other labs’ concerns,” Dr. Sesok-Pizzini says. “This is a way to have other labs see what we do in other areas.” Technologists gain knowledge of the tests performed in other laboratories and identify issues common to multiple laboratories, “potentially allowing for process improvement opportunities that affect patient care,” she says.

As important as the tours are, they’re not the only component of CHOP’s patient safety improvement efforts. Rather, they’re part of a larger approach that includes many elements, such as a daily patient-safety conference call with participants from nursing, bed management, pharmacy, laboratory, and other major departments. “Each group has a representative that reports on anything happening in their own area that could affect patient safety,” Blecker-Shelly says. “It’s overseen by a hospital vice president. It’s a way to connect people when there are problems, and it gives everyone a sense of what’s happening organizationwide with regard to safety.”

Then, too, “we’ve been very proactive about never events,” Dr. Sesok-Pizzini says. For example, CHOP has implemented a laboratorywide system to ensure that if a mislabeled specimen shows up in chemistry, the blood bank is notified, in case “there’s a specimen in blood bank [from the same patient] that is also mislabeled. That policy is not required by any regulatory body we’re aware of. I think that is very proactive, recognizing a potential process failure that could have significant impact.” In addition, Blecker-Shelly says, “we’ve revised our specimen-labeling policy to make it more stringent and allow physicians to relabel and come up and identify a specimen less often. Now that’s only allowed for irretrievable specimens.”

In addition, the blood bank offers a teaching program for pediatric hematology/oncology and anesthesia and critical care fellows. “About four years ago, we started inviting them into the blood bank because of a patient safety issue, a mislabeled specimen,” Dr. Sesok-Pizzini explains. “We take two fellows per month. Why anesthesia and critical care? We found they often needed the blood the quickest but had the least amount of experience with the blood bank. Even though hematology/oncology may use the most blood in the hospital, they’re not using it as urgently as the critical care team is.” That’s why the program’s aims include educating the fellows about turnaround time. “We’re a pediatric hospital, and for some of our smaller babies with potassium concerns, we wash the blood. That takes up to an hour—and you can’t get that stat when a patient is bleeding. Seeing the process and understanding why things take as long as they do has been a really outstanding experience for them,” Dr. Sesok-Pizzini says.

After fellows complete the program, says blood bank quality manager Carmelita Moultrie-Savage, MT(ASCP)BB, “we get positive feedback from them” to the effect that they’re better able to make decisions in emergency situations. “They know what’s required with the sample, and they’ll call us and say, ‘I can’t get that amount. Should I send what I have to see if you can work with it?’”

And then there are the hospital’s 10 patient safety officers, who report to the chief medical officer. Their purpose is not only to serve as a liaison between their clinical areas and senior administrator, but also to ensure that patient safety incidents are addressed as quickly as possible. “Patient safety officers can reach out to the different personnel in their department and come up with quicker corrective action plans than we could do as an overall institution by looking at root-cause analysis,” Dr. Sesok-Pizzini explains. “It’s a way to correct problems early.”

An example: “When our LIS went down last week,” she says, “we were informed that some of the clinical staff were not informed about this and did not realize there was a potential for some critical labs to be missed by the LIS. So we immediately went back to our LIS group and said, ‘You know what, we have some concerns in this area.’ Within a week’s time they realized they could have used a more extensive paging system and perhaps put a banner on the hospital’s information system log-in screen to alert people that there were important labs they might be missing because of this downtime.”

(She adds that “root-cause analysis continues to occur for our most significant patient safety events.” For less significant events, “we perform an apparent-cause analysis, and the events are analyzed locally on each unit or by each department. Feedback from apparent-cause analyses is forwarded to our office of patient safety and quality for review.”)

Underpinning all of these patient safety efforts, of course, is the hospital’s electronic safety-event reporting system. “We are continuing to encourage people to report patient safety events in the system,” Blecker-Shelly says. “That system has been operational for about two years now, and we really obtain a lot of data from it. We had another way of tracking labeling errors for years before the electronic system went online, but it never really led to any action.”

Looking ahead, Dr. Sesok-Pizzini says, “we’re going to have safety coaches in different areas—people who will act as mentors, who will model behaviors such as practicing with a questioning attitude and communicating clearly.” Those coaches will, she hopes, help create a culture in which “if you see someone doing something not correctly, you say, in a very kind and professional way, ‘Hey, this is not what we’re supposed to be doing,’ without it being perceived as negative or inflammatory,” no matter what positions the people involved hold. “We’ve worked really hard on trying to flatten the hierarchy, so that people feel very comfortable giving feedback to others no matter what their role.”

Anne Ford is a writer in Evanston, Ill.