Trials for errors: how one lab fixed reporting flaws

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Dr. Steele

Soon the huddles were outfitted with white boards, and their popularity grew. “It’s a great way for everybody to know what’s going on. If you weren’t at the huddle and you came in later, you could look at that board and know exactly what’s going on in that area,” she says.

The huddle boards inspired a noticeable improvement in the effectiveness of laboratory medicine at CCHMC, Dr. Steele recalls. “One patient in particular had a lot of trouble with his coagulation studies. This child was in the ICU with a ventricular assist device. These patients are very fragile; they’re sort of on a razor edge between bleeding and clotting because of that device.”

For Good, the laboratory’s experience with that patient “brought everything home.”

“Everybody was on the lookout for the samples whenever it was posted on the huddle board that this patient was in and having a surgical procedure. We were so used to seeing that name and having challenges with their samples that when it ultimately came time for the final surgical procedure, there was a lot of excitement in the lab.”

By fall 2013 CCHMC had implemented drop-down menu definitions for microbiology and a new bilirubin rule that would prevent results from being released if the total bilirubin was lower than the direct bilirubin. The team began to sense an important transformation in the laboratory, and the numbers soon confirmed their hunch: From April to October 2013, test accuracy at CCHMC improved from around 5.4 to 1.2 errors per 10,000 reported results.

Two final interventions, interfaces for the Mini Vidas and Clinitek systems, were implemented in January 2014. But by then, error rates were at record lows. Current rates at CCHMC continue to hover around one error per 10,000 results.

As they were heading into 2015, the laboratory was planning to continue interfacing its small benchtop instruments and expanding autoverification.

“We’re looking for devices that can be interfaced to remove the human error in the manually entered results. But we also reordered our barcode scanners. We used to have them all over the place, and then as they broke or were moved to a different bench, they got to be fewer and farther between,” Good says. “We’ve gone back and reassessed our hardware. Where do the scanners need to be placed to make sure that every workstation is equipped in the same manner? It shouldn’t matter if I’m working on this bench or that bench—I should have a scanner, I should have the right PC, I should know where my printer is. Those kinds of things can take away a little of that variability based on what bench I might be happening to sit at for the day.”

On CCHMC’s annual performance management system, technologists and technicians are asked to commit to the goal of keeping the institution’s error rate well below 2.3 per 10,000 reported results. “In 2014, they well exceeded that goal,” Pace says.

Looking back, Good says the project’s success is largely due to the team’s ability to cultivate an environment where errors are discussed openly and where root causes are determined. “Hard work and careful reminders are simply not enough to consistently ensure error-free work. It takes good processes, committed people, and reliable systems to make sure everyone is working together,” Good says. “That makes all the difference.”
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Ann Griswold is a writer in San Francisco.