We studied the inter-departmental coordination of information between the ED and the clinical laboratory in a metropolitan medical center with approximately 77,000 ED patient visits yearly.
Our primary goal was to identify sources of pre-analytical error in laboratory testing and delays in reporting laboratory results, and to generate possible solutions to these problems.
We conducted detailed field observations (69.5 hours) of physicians, nurses, paramedics, patient care technicians, patients, laboratory technologists, and administrative staff, combined with interviews of selected staff members in the ED and the clinical laboratory. Instances of patient sample mislabeling and delayed laboratory test results were directly observed. We analyzed the temporal and spatial flows of people, samples and information within and across the departmental boundaries to determine the root causes of the observed errors and delays.
We found that fundamental to the labeling errors and delays in laboratory testing is that the two departments operate under very different temporal systems. The ED is organized to cope with multiple concurrent tasks, while the laboratory operates within a more linear temporal framework that reflects the sequential nature of the testing process. To cope with such asymmetrical temporal systems, the members of the ED created “work-arounds” of usual procedures (such as drawing blood samples before a patient was registered), which often became sources of errors. Furthermore, we found that the lack of local awareness of critical events and status of work activity within and between the ED and laboratory created additional errors and delays.
Our findings suggest that it may be important to consider how different temporal systems affect interacting groups of healthcare workers in order to improve efficiency of healthcare delivery and reduce medical error. Additional study is needed to determine effective mechanisms (both organizational and technological) to improve coordination between interacting temporal systems.
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