Preanalytical errors in hospitals. Current research and process-oriented improvement initiatives Labquality Days Helsinki 2009 Olof Wallin, MD/PhD

Transcription

1 Preanalytical errors in hospitals Current research and process-oriented improvement initiatives Labquality Days Helsinki 2009 Olof Wallin, MD/PhD

2 Main topics The total testing process Preanalytical errors Research project at Umeå University: Survey of preanalytical procedures Evaluation of pneumatic tube transport Patient focused lead-times for the total testing process Improving flow in the total testing process 2

3 The total testing process The patient Prepreanalytical Postpostanalytical Pre-analytical Post-analytical Analytical 3

4 Where are the errors located? Pre-analytical % Analytical 7-3 % Post-analytical 9-47 % Ordering the test Test request Patient identification Patient pr eparation Labelling Sample collection Sample handling Transport Sample handling Equip ment function Analytic impr ecision Information technology Test re sult Transcription Inter pretation Turn-around time Information technology 4 Kalra. Medical Errors: Impact on Clinical Laboratories and Other Critical Areas. Clin Biochem 2004:37:

5 The research project at Umeå University -venous blood sampling Study Study 2 Study 3 Study 4 Study 5 5 Thesis available free at:

6 Study -4: Methods Questionnaire survey Ward and laboratory staff responsible for the majority of the sample collection Standard method for venous blood sample collection for general clinical chemistry Study : Pilot study One ward at a university hospital Study 2-4: Main study All wards in two hospitals and two clinical chemistry hospital laboratories 6

7 Participant characteristics Wards Laboratories Participants (n) Woman (%) Enrolled nurses (%) 9 5 Biomedical technicians (%) 0 95 Sample collection every week (%) Routines (%) 6 00 Accreditation (%) 0 00 Competence certificate (%) 0 00 Re-education (%) 6 30 Want education (%) Want increased responsibility (%) 44-7

8 Study 2: Results Wallin et al. Preanalytical venous blood sampling practices demand improvement A survey of test-request management, test-tube labelling and information search procedures. Clin Chim Acta ;9-7. How often do you perform the following tasks? Never Seldom Often Always Total Compare the patient's name/id-nr with the test-request (%)* Check the information on test-requests completed by somebody else (%)* Wards Lab Wards Lab Shaded areas indicates the desirable practice of the item. *Significant differences between wards and laboratories: p=0.034; p=

9 Study 2: Results 2 When do you label the test-tube? Never Seldom Often Always Total Alongside the patient, immediately before sample collection* (%) Wards Lab Where do you search for information when not sure in how a sample should be collected? Never Seldom Often Always Total Use the online manual* (%) Wards Lab Shaded areas indicates the desirable practice of the item. *Significant differences between wards and laboratories: p<0.00; p<

10 Study 3: Results Wallin et al. Blood sample collection and patient identification demand improvement. A questionnaire study of preanalytical practices in hospital wards and laboratories. Submitted. How and how often do you check the identity of the patient when collecting venous blood samples? By asking the patient to state name and ID-nr (%) By checking the ID-wristband (%) Always Wards 90 Lab 94 Wards 22 Lab - Total Shaded areas indicates the desirable practice of the item. No significant differences between wards and laboratories. 0

11 Study 3: Results 2 For how long do you usually allow your patient to rest prior to sample collection? 0-5 min >5 min Do not check Total Wards* (%) 8 Lab* (%) 33 Shaded areas indicates the desirable practice of the item. *Significant differences between wards and laboratories.

12 Study 2 & 3: Overall results No significant associations between re-education or documented routines and results To what extent do you agree in the following statements? Enough knowledge for daily work with sample collection (%) Proper collection of samples is a priority at my ward (%) Not at all To some extent Totally Total Wards Wards

13 Study 4: Results Wallin et al. A questionnaire survey of error reporting practices regarding venous blood sampling in hospitals. Manuscript. How many incident reports have you filed after observing or making an error in venous blood sampling? Wards Laboratories Have never filed an incident report* 95 % 72 % *Significant differences between wards and laboratories. 3

14 Study 5: Methods Wallin et al. Effects of pneumatic tube transport of venous blood on platelet function, global coagulation and routine hematology and coagulation analysis. Clin Chem Lab Med ; Healthy subjects Befor e/after 75 mg ASA/day Duplicate samples: PTT and Non-PTT 4 Graphical summary of PTT: Courtesy of the Dept. of Biomedical Engineering and Informatics, Umeå University Hospital

15 Study 5: Results Regular hematology and coagulation parameters not affected Platelet function (PFA-00) not affected: Contrasting earlier report Discrepancy between duplicate samples observed as earlier described 2 Decrease in time to clot formation in the thromboelastograph (R: -6%, p=0.037) 5 Dyszkiewicz et al. The effect of pneumatic tube transport on PFA-00 closure time. J Thromb Haemost 2004;2: Madsen et al. Test of aspirin resistance by PFA-00 some methodological caveats and considerations. J Thromb Haemost 2008;94:3-8.

16 Conclusions Sampling instructions not followed risk of preanalytical errors Staff interested in education and increased responsibility Laboratory staff reported better practices Education and routines not associated with reported practices Incident reporting uncommon PTT not recommended for analysis with thromboelastograpic techniques 6

17 Implications Examination of the preanalytical process recommended Focus on patient identification and test tube labelling Majority of staff woman gender perspective Reconsider use of incident reports structured patient record surveys Evaluation of PTT on coagulation tests recommended 7

18 Flow of information from brain to brain The patient Pre- preanalytical Post-postanalytical Pre-analytical Post-analytical Analytical 8

19 Lead-times in the total testing process ER One, first request, last result ER Two, first request, last result 9

20 Lead-times in the total testing process ER One: Sample collection after physician, last result ER Two: Sample collection after physician, last result Physician -> Test result 7:00 6:00 5:00 4:00 3:00 2:00 :00 UCL=4: _ X=:32 Physician -> Test result 7:00 6:00 5:00 4:00 3:00 2:00 :00 UCL=4:32 _ X=2:06 0:00 LB=0:00 0:00 LB=0: Consecutive patients Consecutive patients

21 Improving flow in the total testing process Value adding activities for the patient Data, data, data - patient focused, from end to end Increased responsibility for the total testing process by the laboratory Interdisciplinary improvement team Pareto principle - from the patients point of view Adjust, test and evaluate suitable measures Systematic involvement of the management 2

22 Thank you! Thesis available at: Acknowledgements: Christine Brulin, Kjell Grankvist, Johan Hultdin, Johan Söderberg, Andreas Jonsson, all at Umeå University. 22