|
By Cindy Johnson
10/09/07
Patient Safety is Non-Negotiable
Cindy Johnson
“Patient safety is non-negotiable” is
the mantra that has been adopted by CentraCare
Laboratory Services (CCLS) over
the past year. Numerous staff-driven process improvement projects have been
initiated and are in development with a primary focus on patient safety. We
owe it to our patients to provide the most accurate diagnostic information
in a timely manner.
This process starts with properly identifying the patient. The Joint Commission
National Patient Safety Goal #1 is to improve the accuracy of patient identification,
including the use of at least two patient identifiers when providing care,
treatment, or services. In our hospital inpatient setting, the facility has
adopted the use of a patient’s name and medical record as standardized
forms of identification. While the laboratory’s information system (LIS)
generates bar-coded labels with complete patient demographics for comparison
to patient identification armbands, these labels are not always available to
the personnel who are collecting patient samples. To address this issue, CCLS
has implemented a policy that requires verbal delivery of patient information
to be documented and confirmed with a read-back protocol. This assures that
the proper information has been communicated for accurate patient identification.
In the outpatient setting, our patients do not have identification armbands.
Therefore, CCLS has adopted the practice of using verbal confirmation of the
patient name and date of birth as the standardized forms of identification.
Furthermore, upon completion of labeling a specimen, we verify that the information
is correct by showing the patient the properly labeled specimen containers.
Our patients have frequently stated that they have found this practice reassuring
because they can actually validate that their specimens have been labeled correctly.
So that all specimens arrive with a consistent and complete format, our labeling
policy was developed to standardize the procedure staff use to collect all
specimens. This policy includes practices for utilizing LIS labels, patient
chart labels, and hand-written practices. We have recently revised the specimen
labeling policy to also include a standardized approach to re-labeling specimens.
The core of this practice is that when additional labeling is required, demographic
information from the original label remains visible. This allows for a validation
chain of the sample’s identification. Staff members assume responsibility
for this re-labeling by initialing the added label, which allows us the opportunity
to track handling of the samples.
One of our challenges has been incomplete and variable specimen labeling practices
from entities that are external to our laboratory sites. CCLS is committed
to working with our nursing units, clinics, and outreach clients to increase
compliance with this patient safety goal. Visual documents have been created
for distribution to standardize the labeling practice throughout our client
base. Additional tools are in development to aid our clients in this patient
safety initiative.
As a component of the CCLS Quality Performance Improvement Program, our laboratory
is tracking all patient identification and specimen labeling errors, both internal
and external. The purpose of the tracking is to utilize data for education,
training, and identification of additional process improvement opportunities.
The data is graphed and posted to allow staff to see our development. In addition,
staff members have created a unique tool for tracking and celebrating our progress:
A safety sign tracks days that CCLS remains patient or sample-identification
error-free. It also records previous records and future goals. This has been
a great opportunity to engage staff in patient safety.
CCLS continues to stress the importance of patient safety through our Quality
Assurance Programs and Performance Improvement Teams. Opportunities have been
created to enhance patient and sample identification, educate staff and clients,
and document, measure, and celebrate success. As further opportunities are
identified, staff involvement will continue to be essential in process improvement
initiatives with the underlying premise that “Patient safety is non-negotiable.”
|
