Patient Safety for Laboratory Professionals Online Training

Welcome to the Patient Safety for Laboratory Professionals Online Training course.  In this course we will discuss the importance of recognizing laboratory errors that can lead to patient harm and ways to avoid occurrence and recurrence of these types of errors.   This presentation was authored by: Susan Morris, MPH, MLS(ASCP)CM Patient Safety Officer St Luke’s Magic Valley Medical Center Twin Falls, Idaho Select Next to continue.     Upon successful completion of this course, you will be able to: Recognize how laboratory errors can cause harm to patients Apply the Institute of Medicine quality aims to laboratory services Describe the benefits to patient safety by decreasing the punitive focus for an individual when errors do occur Discuss things patients and their families can be encouraged to do that improve the safety of their laboratory services   Select Next to continue. The focus of the 1999 Institute of Medicine report “To Err Is Human” was to gain the nation's attention on the prevention of harm in the healthcare system. Over the past century multiple centers of excellence were created to provide the most advanced care and treatment.  Laboratory services are examples of such centers of excellence. Select Next to continue. 275 lives lost 275 lives every   day   Select Next to continue. “This problem is unlike cancer, AIDS, or other diseases, where we must wait for a scientific breakthrough in order to save lives. Hospital errors are a man-made epidemic. Healthcare professionals make mistakes, and lives are being lost. These human errors need a human solution”. Select Next to continue.     The prevention of harm to patients associated with health care. Patient Safety emphasizes the reporting, analysis, and prevention of healthcare errors that can lead to patient harm. Select Next to continue.     Inappropriate or unnecessary invasive procedures due to incorrect results reported   Death or permanent injury due to delays in critical treatments or procedures  caused by missing test results   Hemolytic transfusion reaction to  incompatible blood products   Select Next to continue. Pre-Analytic Test ordering Specimen collection Specimen transport Analytic Test performance Verification of results Post-Analytic Results reporting Follow up test orders Diagnosis established Treatment decisions Pre-Analytic Test ordering Specimen collection Specimen transport Analytic Test performance Verification of results Post-Analytic Results reporting Follow up test orders Diagnosis established Treatment decisions             Pre-Analytic Test ordering Specimen collection Specimen transport Analytic Test performance Verification of results Post-Analytic Results reporting Follow up test orders Diagnosis established Treatment decisions Pre-Analytic Test ordering Specimen collection Specimen transport Analytic Test performance Verification of results Post-Analytic Results reporting Follow up test orders Diagnosis established Treatment decisions Select Next to continue. Safe Timely Effective Efficient Equitable Patient-Centered Select Next to continue. Avoids injuries to patients Protocols for preventing iatrogenic anemia   Systems to prevent laboratory test results being reported on the wrong patient   Procedures for prevention of the spread of infections during patient interactions   Specimen collection protocols to prevent inaccurate results due to mis-handled specimens   Select Next to continue. Reduces waiting and harmful delays Reporting critical test results to clinician Select Next to continue. Right services provided   Evidence-based testing algorithms help providers with test selection   Elimination of outdated  testing methods   Protocols for dealing with compromised specimens   Select Next to continue. Avoids waste Appropriate test ordering Select Next to continue. Interpreter services Simple educational materials and instructions Appropriate language and health literacy reading level Scheduling times that are available outside of regular work hours Select Next to continue. Patient needs first Involving the patient in verifying correct identity, correct orders, and specimen labeling Giving patients information about how they can obtain a copy of their results Providing resources to help answer patient’s questions about their laboratory services Select Next to continue. You can’t fix problems that you don’t know about   Staff need to feel safe to report errors   “The single greatest impediment to error prevention is that we punish people for making mistakes.”                           Lucian Leape Select Next to continue. Focusing on the person who made the error leaves the underlying flaws in the “system” unaddressed. Select Next to continue. We cannot control when or where a human error will occur but we can control intended behaviors thereby reducing the likelihood of making a mistake. Select Next to continue. Focus on assigning blame OR Emphasize learning from the mistake how to prevent future harm Select Next to continue.   Emphasizes learning rather than blame   Create structures that help people reveal their error and help the organization learn from them   Holds people accountable for knowingly putting someone at risk   Select Next to continue. A recent focus on patient experience scores and numerous complaints from patients about not getting enough rest while in the hospital had the phlebotomist mistakenly believe that not waking the patient was a better patient outcome that outweighed the risk of not following the patient ID standard. How prevalent is this behavior? Why are people doing this? How can we put systems in place that will encourage or force the correct behavior? And how can we help people comprehend the risk that exists so they will make the right behavioral choice? Select Next to continue. Require employees to speak up. Select Next to continue.     The NPSF Patient Safety Congress is your annual opportunity to learn from and exchange ideas with patient safety experts and practitioners from around the globe. Carefully crafted by leaders in the field to provide real-world tools, resources, and evidence-based solutions to patient safety issues, the NPSF Patient Safety Congress is the foremost learning and networking event for the field. Select Next to continue. Encourages patients to share responsibility for their own safety. Select Next to continue. In a culture of safety...patients know what to expect. Patients and families have the greatest stake in preventing medical errors., and can be an important source of information to help prevent potential adverse events and hazardous conditions. Select Next to continue.   Medical Laboratory Scientists - highly educated about lab tests and testing processes, but rarely in a position to talk to a patient.  Phlebotomists - handle almost all of the patient interactions, but may lack the specialized education necessary to answer patient questions or explain laboratory tests. Select Next to continue. √ To request information that they can understand about the tests that have been ordered by their provider - Including cost √ To refuse a test √ To understand the specimen collection procedure   √ To understand possible complications of phlebotomy and what to do if they occur √ To know about when results will be available to their Provider √ To be told how they can request a copy of their test   Select Next to continue. Encourage patients to be actively involved: Give them permission to speak up Give them expectations for the timeliness of results Select Next to continue. 4600 American women died of cervical cancer in 2000. Patients need to know: When they can expect to hear from their physician about their results When they should contact their physician if they have not heard anything And they can request a copy of their results Select Next to continue. Select Next to continue. Quality laboratory care must be: Safe Timely Effective Efficient Equitable Patient-centered Select Next to continue. Ways to involve patients in their laboratory services include: •Communicate with patients about safety •Actively involve patient in safety procedures •Be accountable to your patients •Give patients tools for safety •Provide information that patients can understand and that is culturally sensitive   Select Next to continue.