2.50
Hdl Handle:
http://hdl.handle.net/10755/162535
Type:
Presentation
Title:
2008 Year of the Interface (Whose Blood is this Anyway?)
Abstract:
2008 Year of the Interface (Whose Blood is this Anyway?)
Conference Sponsor:Emergency Nurses Association
Conference Year:2009
Author:Murphy, Paula, RN, BSN, CEN, CWCN
P.I. Institution Name:Johns Hopkins Hospital
Title:Orientation Facilitator
Contact Address:600 North Wolfe Street, Baltimore, MD, 21287, USA
Contact Telephone:410-955-2280
Co-Authors:Peter Hill, MD, FACEP; Heather Gardner, RN, MSN, CEN
[Annual Conference] Clinical Topic: Accurate identification of laboratory specimens is crucially important to managing patient care and directing decision-making regarding medical interventions. This undeniably exemplifies current patient safety practices.
An emergency department in a large, urban teaching hospital had a history of ongoing significant specimen labeling errors (unlabeled and mislabeled specimens). The specimen labeling procedure involved creating requisitions and labels by hand, and required bedside labeling of specimens. Despite diligent oversight the error rate was unsatisfactorily high (0.41%).
Typical interventions included staff dedicated to timely collection and analysis of data, re-education, new process designs, reorganization of workspaces, and establishment of communication pathways. In addition, the institution created an interdisciplinary team with multiple perspectives to investigate, identify and incorporate the unique characteristics and obstacles present in the emergency department. Still, the error rate remained unchanged. The last resort, regretfully, was the hazard of disciplinary action for repeated errors.
While continuing the audit of labeling errors it was clear that there was need for a powerfully creative and drastic intervention.
Our purpose was to reduce errors associated with incorrect labeling and identification of laboratory specimens, to achieve an error rate below the hospital wide target of 0.21%, and thereby decrease the risk of threats to patient safety.

Implementation: The first intervention was implementation of a comprehensive emergency department electronic documentation and information system, including physician order entry; the second was introduction of bar coded patient wrist bands and bar coded specimen labels, along with an interfaced bedside, barcode-driven specimen and patient verification system.
Retrospective data evaluation included the total number of specimens collected pre and post-intervention, the total number of specimens cancelled due to labeling errors, and the percentage of errors and reasons for cancellation.

Outcomes: We describe a four and one-half year observational study (May 2005- January 2009) with a two component intervention implemented on April 29, 2008. Results: 532,151 specimens were collected pre-intervention with 2182 errors (0.41%) and 136,711 specimens were collected post-intervention with 158 errors (0.12%) - a nearly 4 fold reduction in errors as a result of the intervention. Analysis of the remaining errors reveals that the majority occur when this new process cannot be used, such as specimens for the blood bank or surgical pathology.
Recommendations: In a climate of heightened focus on patient safety and a recognized overcrowded, demanding environment of US emergency departments, it becomes the responsibility of nursing to be persistent in requiring our institutions to pursue technology that responds to the specific and intrinsic characteristics of staff behavior. This technology must be a catalyst in reducing the risks of human error. Our experience shows that by combining a physician order entry system with bar coded patient wrist bands, specimen labels and a bedside electronic specimen and patient verification process, specimen labeling errors can be significantly reduced. Further recommendations include thorough and sensitive staff education, a solidly planned workflow, considerations for best practice, incorporation of clinical staff feedback and engagement, and concurrence that optimal patient outcome is the clear priority.
Repository Posting Date:
27-Oct-2011
Date of Publication:
17-Oct-2011
Sponsors:
Emergency Nurses Association

Full metadata record

DC FieldValue Language
dc.typePresentationen_GB
dc.title2008 Year of the Interface (Whose Blood is this Anyway?)en_GB
dc.identifier.urihttp://hdl.handle.net/10755/162535-
dc.description.abstract<table><tr><td colspan="2" class="item-title">2008 Year of the Interface (Whose Blood is this Anyway?)</td></tr><tr class="item-sponsor"><td class="label">Conference Sponsor:</td><td class="value">Emergency Nurses Association</td></tr><tr class="item-year"><td class="label">Conference Year:</td><td class="value">2009</td></tr><tr class="item-author"><td class="label">Author:</td><td class="value">Murphy, Paula, RN, BSN, CEN, CWCN</td></tr><tr class="item-institute"><td class="label">P.I. Institution Name:</td><td class="value">Johns Hopkins Hospital</td></tr><tr class="item-author-title"><td class="label">Title:</td><td class="value">Orientation Facilitator</td></tr><tr class="item-address"><td class="label">Contact Address:</td><td class="value">600 North Wolfe Street, Baltimore, MD, 21287, USA</td></tr><tr class="item-phone"><td class="label">Contact Telephone:</td><td class="value">410-955-2280</td></tr><tr class="item-email"><td class="label">Email:</td><td class="value">pamurphy@jhmi.edu</td></tr><tr class="item-co-authors"><td class="label">Co-Authors:</td><td class="value">Peter Hill, MD, FACEP; Heather Gardner, RN, MSN, CEN</td></tr><tr><td colspan="2" class="item-abstract">[Annual Conference] Clinical Topic: Accurate identification of laboratory specimens is crucially important to managing patient care and directing decision-making regarding medical interventions. This undeniably exemplifies current patient safety practices.<br/> An emergency department in a large, urban teaching hospital had a history of ongoing significant specimen labeling errors (unlabeled and mislabeled specimens). The specimen labeling procedure involved creating requisitions and labels by hand, and required bedside labeling of specimens. Despite diligent oversight the error rate was unsatisfactorily high (0.41%).<br/> Typical interventions included staff dedicated to timely collection and analysis of data, re-education, new process designs, reorganization of workspaces, and establishment of communication pathways. In addition, the institution created an interdisciplinary team with multiple perspectives to investigate, identify and incorporate the unique characteristics and obstacles present in the emergency department. Still, the error rate remained unchanged. The last resort, regretfully, was the hazard of disciplinary action for repeated errors. <br/>While continuing the audit of labeling errors it was clear that there was need for a powerfully creative and drastic intervention.<br/> Our purpose was to reduce errors associated with incorrect labeling and identification of laboratory specimens, to achieve an error rate below the hospital wide target of 0.21%, and thereby decrease the risk of threats to patient safety.<br/><br/>Implementation: The first intervention was implementation of a comprehensive emergency department electronic documentation and information system, including physician order entry; the second was introduction of bar coded patient wrist bands and bar coded specimen labels, along with an interfaced bedside, barcode-driven specimen and patient verification system. <br/>Retrospective data evaluation included the total number of specimens collected pre and post-intervention, the total number of specimens cancelled due to labeling errors, and the percentage of errors and reasons for cancellation.<br/><br/>Outcomes: We describe a four and one-half year observational study (May 2005- January 2009) with a two component intervention implemented on April 29, 2008. Results: 532,151 specimens were collected pre-intervention with 2182 errors (0.41%) and 136,711 specimens were collected post-intervention with 158 errors (0.12%) - a nearly 4 fold reduction in errors as a result of the intervention. Analysis of the remaining errors reveals that the majority occur when this new process cannot be used, such as specimens for the blood bank or surgical pathology.<br/>Recommendations: In a climate of heightened focus on patient safety and a recognized overcrowded, demanding environment of US emergency departments, it becomes the responsibility of nursing to be persistent in requiring our institutions to pursue technology that responds to the specific and intrinsic characteristics of staff behavior. This technology must be a catalyst in reducing the risks of human error. Our experience shows that by combining a physician order entry system with bar coded patient wrist bands, specimen labels and a bedside electronic specimen and patient verification process, specimen labeling errors can be significantly reduced. Further recommendations include thorough and sensitive staff education, a solidly planned workflow, considerations for best practice, incorporation of clinical staff feedback and engagement, and concurrence that optimal patient outcome is the clear priority.<br/></td></tr></table>en_GB
dc.date.available2011-10-27T10:29:50Z-
dc.date.issued2011-10-17en_GB
dc.date.accessioned2011-10-27T10:29:50Z-
dc.description.sponsorshipEmergency Nurses Associationen_GB
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