Thursday, April 28, 2005

The Science of Patient Safety: Longitudinal Studies in an Environment of Change. Wagar, E. A.* Hilborne, L. H., Yasin, B. Tamashiro, L., Bruckner, D.A. UCLA Healthcare and Department of Pathology and Lab. Medicine, David Geffen School of Medicine, UCLA

Elizabeth A. Wagar, Lee H. Hilborne, Bushra Yasin, Lorraine L. Tamashiro, and David A. Bruckner.

Patient safety projects are exposed to many extrinsic influences in the healthcare environment. Examples of such influences are changes in public safety awareness, facilities modifications, and leadership transitions.

Despite these influences, healthcare providers must be able to explicitly demonstrate improvements resulting from each patient safety initiative implemented.

UCLA Clinical Laboratories initiated a patient identification safety initiative in November, 2002, with continuous data collection for three categories of critical patient specimen errors: 1) unlabeled specimens, 2) specimen/requisition mismatch, and 3) mislabeled specimens. Mislabeled specimens are especially hazardous because they are both latent and invisible. These errors are only discovered after laboratory results do not match up with patient conditions (“wrong blood in tube”).
UCLA Clinical Laboratories receive approximately 6500 specimens and 3500 phlebotomy requests daily. The occurrence of the 3 error types was followed over a 19 month period, during which a number of extrinsic influences (e.g., increased public awareness) occurred.
Three patient safety activities were introduced at 4, 10, and 14 months. At 4 months, the laboratory began providing phlebotomy services around the clock; nursing in-service education was performed for ICU nursing phlebotomy. At 10 months, an electronic event reporting system was instituted system-wide. At 14 months, an automated processing system was activated in specimen receiving.
Statistical analysis using paired Student's t-test was conducted to measure and compare unlabeled specimens, specimen/ requisition mismatches and mislabeled specimens before and after interventions.

At 19 months, all 3 categories showed significant or close to significant decreases compared to performance before any of these patient safety initiatives began (p = 0.014, 0.001 and 0.002 for mislabeled specimens, requisition mismatch, and unlabelled specimens respectively).

Our findings demonstrate the ability to decrease the incidence of critical errors in an environment of change.

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