Pennsylvania Patient Safety Authority Releases September Advisory

Thursday, September 17, 2009 General News
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Pocono Medical Center and facilities in the northeast work together to reduce the number

of laboratory errors due to specimen mislabeling

HARRISBURG, Pa., Sept. 16 /PRNewswire-USNewswire/ -- Healthcare facilities in northeast Pennsylvania have come together to reduce and eliminate laboratory errors due to specimen mislabeling. Pocono Medical Center helped to spearhead the effort when they noticed they were reporting a large number of mislabeled lab specimens at their facility that coincided with data delivered in a presentation by the Pennsylvania Patient Safety Authority.

"The Authority spoke at an event for Pocono Medical Center in January and gave a presentation about Pennsylvania hospital data," Fran Charney, director of educational programs for the Pennsylvania Patient Safety Authority, said. "The Authority's specimen mislabeling data sparked a particular interest in Pocono and they approached the Authority to help improve patient safety in this area. The Authority agreed to facilitate a collaborative of area facilities to work on the issue."

Charney oversees the Authority's Patient Safety Liaison (PSL) program that has Authority representatives going into Pennsylvania's facilities to help them implement Pennsylvania Patient Safety Advisory guidance and improve patient safety processes. Pocono Medical Center's Patient Safety Officer (PSO) worked with the Northeast PSL, Megan Shetterly, to develop the collaboration.

Charney said analysis of Authority data shows that mislabeling events occur more often in the Emergency Department (ED) than other care areas, which is consistent with findings reported in literature that show laboratory samples drawn in the ED were 10 times more likely to be mislabeled. Specific to the northeast region, Authority analysis shows there is one mislabeling event reported per facility per month. Unfortunately, the Authority believes there are probably more mislabeling events that go unreported.

"Pocono Medical Center uses their laboratory information system to specifically track mislabeling errors," Charney said. "Many events are most likely missed, especially near-miss events, in other facilities if they do not have a process to track these specific events. Existing processes within facilities need to be examined and changed, if necessary, to be able to track these events more thoroughly."

Charney added that the collaboration will help facilities track these events more carefully and then more process changes will occur to reduce the chances of a healthcare provider mislabeling a patient's lab specimen. Ten hospitals and one rehabilitation facility are participating in the collaborative. To ensure participating facilities will collect the correct events for analysis, they were encouraged to compare specimen mislabeling events submitted to the Authority to other data, such as the number of redraws per month and the number of specimens wasted per month.

Two key elements were identified by the participants for this purpose: 1) the definition of phlebotomy specimen mislabeling and 2) the list of questions (taxonomy) under which these events will be reported to the Authority.

"It is so important for facilities to work together to solve problems, particularly in regard to this project," Charney said. "We must ensure that the data we are collecting for the project is standardized so we can analyze the loopholes in processes that are causing the mislabeling to occur and thereby provide guidance to prevent any future mislabeling of lab specimens."

Charney said the Authority will provide education, technical assistance, tools, resources and an interactive forum to facilitate participants' efforts to improve patient safety with phlebotomy specimen mislabeling prevention. She added that success of the project depends upon a high level of commitment from patient safety officers, laboratory directors, information technology personnel, nursing leaders, physician champions, senior leaders and frontline staff.

A list of the anticipated benefits of the collaboration include a learning network for facilities in the northeast of Pennsylvania to help reduce and eliminate phlebotomy specimen mislabeling and new educational processes designed to eliminate common human behaviors that might cause an error to occur.

A complete list of the anticipated benefits is included in the 2009 September Pennsylvania Patient Safety Advisory article "Collaborative Patient Safety Effort: Addressing Phlebotomy Specimen Mislabeling." Future Advisory articles will also give updates on best practices identified within the collaboration.

The Authority's quarterly September Advisory contains other articles developed from data submitted about real events that have occurred in Pennsylvania's healthcare facilities. The articles also provide advice and prevention strategies for facilities to implement within their own institutions. Highlights include:

For the complete 2009 September Pennsylvania Patient Safety Advisory, go to For toolkits and other educational information go to the Authority's Web site and click on "Educational Tools."

-- Medication Monitoring Errors: More than 2,500 event reports submitted to the Authority were specifically classified as errors involving drug-related clinical monitoring. Analysis shows that 48% of the events reached the patient. The medication most frequently involved in these reports was levofloxacin (416 events), a drug that requires dosage adjustments based on renal function. Strategies to address these problems are discussed along with valuable information provided by the facilities that helps pinpoint the exact causes of the errors. -- Connecting Remote Cardiac Monitoring Issues with Care Areas: Patients in noncritical settings may have underlying cardiac conditions or demonstrate unexpected symptoms and condition changes that require constant cardiac monitoring or transfers to a higher level of care, for which treatment may be delayed due to bed unavailability. Many facilities implement remote cardiac monitoring in remote locations to facilitate alarm notification, which alerts healthcare providers about any change in a patient's condition. However, 74% of the 194 Serious Events and Incidents reported to the Authority from June 2004 to December 2008 associated with remote cardiac monitoring were issues with communication and monitoring problems. This article discusses the problems in detail and gives risk reduction strategies facilities can implement to avoid further events. -- Problems with Drainage Tubes: Epidural or subarachnoid catheters (also called lumbar drainage catheters) are very small hollow tubes inserted into patients to administer medications or drain body fluids. Under certain conditions, they can shear, leaving a fragment in the patient. Between June 2004 and December 2008, the Authority received 13 reports related to epidural or subarachnoid catheter shear. Predominant causes of the catheter shear include applying excessive force while removing the catheter and withdrawing the catheter back through the needle. Other causes are listed in this article along with prevention strategies. -- Errors in Radiation Therapy: Radiation therapy is a highly regulated medical practice with historically low error and injury rates. Rare instances of radiation therapy errors resulting in severe injuries (e.g., vital organs) have been documented. This article emphasizes that understanding the technology and therapy is vital to preventing errors, as well as following established practices. -- Barriers to Urinary Catheter Insertion and Management Practices: Despite evidence that catheter-associated urinary tract infections (CAUTIs) and accompanying adverse outcomes can often be prevented; these infections remain among the most predominant healthcare-acquired infections in the United States. In May 2009, hospital infection preventionists (IPs) across Pennsylvania participated in a detailed survey of implementation of urinary catheter insertion and management practices. The survey was designed to measure the level of adoption of practices and tools useful to overcome obstacles to uniform implementation of CAUTI-prevention practices. This article discusses the results of that survey, which were also presented during a webinar held by the Authority in June "Getting Past the Policy: Overcoming Barriers to CAUTI Prevention Practices." The Authority is providing this webinar in a toolkit for healthcare providers as well as reprints of protocols, checklist, reminders, and tips used by other facilities to address CAUTI prevention. -- Wrong-Site Surgery Quarterly Update: The latest update from the Authority's reporting system database shows an encouraging decrease in the number of reports of wrong-site surgery for the third consecutive quarter to an all-time low of six reports. This is the most sustained statewide decrease in wrong-site surgery events to date. Furthermore, a regional collaborative to prevent wrong-site surgeries is also seeing success. More information about the wrong-site surgery project is detailed in this article. Also, a new handout on the Authority's website contains the 21 principles identified during the project that may aid facilities in consistently performing correct-site surgery. However, the Authority will have a full update on the wrong-site surgery project within the next several weeks.

SOURCE Pennsylvania Patient Safety Authority

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