1. Quality Assurance Positive Outcomes for Negative Events Quality Assurance monitors operational systems:Pre-analytical AnalyticalPost-analytical Tools Used: QA Monitors Performance Improvement Customer Needs/Issues- PSN

2. What is a PSN? Patient Safety Net ●Web based method for reporting patient safety issues. ● PSN events can be reported by all staff. ● Not to be used to report Staff Incidents. ● National Consortium of Hospitals utilize PSN. ● Allows hospital to track systematic issues.

3. How do I report a Patient Safety Issue? Notify your Lead, Supervisor and/or Juanita Stem via PDS e-mail. Notify your Lead, Supervisor and/or Juanita Stem via PDS e-mail. Include patient name, history number, specimen number and detail of event. Information will be entered into PSN.

4. What happens to PSN events? Monitored by JHH Patient Safety Committee for trends and potential for patient harm. Monitored by JHH Patient Safety Committee for trends and potential for patient harm. The HEAT Is ON- Hopkins Event Action Team reviews PSN events weekly monitoring for trends and follow-up of PSN events. The HEAT Is ON- Hopkins Event Action Team reviews PSN events weekly monitoring for trends and follow-up of PSN events. Risk Management immediately responds with investigations into PSN events which lead to patient harm. Risk Management immediately responds with investigations into PSN events which lead to patient harm.

5. So how does all this effect Core Laboratory?

6. PSN Events Reported to Core Lab July 1,05 to June 30,06 38Lost/misplaced specimens 32TAT delays 34Phlebotomy issues 17Wrong/modified result 17Keying errors 10Customer Relations

7. PSN Events Reported to Core Lab July 1,05 to June 30,06 9Specimen cancellation issue 9PDS/EPR issue 8Cancellation notification delay 6Processing error 2Miscellaneous TOTAL182 9 Referred to PDS 40No Lab Error identified

8. PSN Events Reported by Core Lab July 1,05 to June 30,06 1348Unlabeled/Mislabeled 1348Unlabeled/Mislabeled 181Clotted specimens for ED and NICU from April,06 to June, 06 181Clotted specimens for ED and NICU from April,06 to June, 06 17Timed draw issues 17Timed draw issues 40Patient identification missing 40Patient identification missing 8Medication misdirected 8Medication misdirected 5Isolation Carts issues 5Isolation Carts issues 5Pneumatic Tube delays/failures 5Pneumatic Tube delays/failures 3CAV notification information missing 3CAV notification information missing TOTAL- 1607 TOTAL- 1607

9. What does Core Lab do with PSNs? - Monitor - Assess - Improve

10. QA Monitors Pre-analytical: Pre-analytical: – Phlebotomy scripting – AM phlebotomy completion times – Phlebotomy cancellations – Phlebotomy error rate – Wrist Band identification – Adult ED Hemolyzed and Clotted Specimens – NICU Clotted Specimens – Requisition Entry – Requisition Completeness – Pneumatic Tube monitor

11. QA Monitors Analytical: Analytical: – Antibiotic cancellations – Coagulation Patient Safety – Shared urine specimen cancellations – TAT: Core Stats Core Stats Superstats Superstats Adult ED Lab Adult ED Lab CCL CCL Inpatient routines Inpatient routines Outpatient routines Outpatient routines

12. QA Monitors Post-analytical: Post-analytical: – PDS Result Review – Electronic Patient Record review – Tracer Methodology – CAV Read Back monitor – CAV TAT within lab within lab RN to Care Provider RN to Care Provider

13. JCAHO Preparation Areas of Concern: Areas of Concern: –NPSG –Proficiency Testing –Electronic Patient Record Lab Results

14. Name a NPSG? Goal 1 Goal 1 Goal 2 Goal 2 Goal 7 Goal 7 Goal 13 Goal 13

15. National Patient Safety Goals Goal 1 Improve the accuracy of patient identification. 1AUse at least two patient identifiers when providing care, treatment or services. 1AUse at least two patient identifiers when providing care, treatment or services. 1BPrior to the start of any invasive procedure, conduct a final verification process, (such as a “time out,”) to confirm the correct patient, procedure and site using active—not passive— communication techniques.

16. National Patient Safety Goals Goal 2 Improve the effectiveness of communication among caregivers. 2AFor verbal or telephone orders or for telephonic reporting of critical test results, verify the complete order or test result by having the person receiving the information record and "read-back" the complete order or test result. 2BStandardize a list of abbreviations, acronyms, symbols, and dose designations that are not to be used throughout the organization.

17. National Patient Safety Goals Goal 2, cont. 2CMeasure, assess and, if appropriate, take action to improve the timeliness of reporting, and the timeliness of receipt by the responsible licensed caregiver, of critical test results and values. 2EImplement a standardized approach to “hand off” communications, including an opportunity to ask and respond to questions.

18. National Patient Safety Goals Goal 7 Reduce the risk of health care- associated infections. 7AComply with current Centers for Disease Control and Prevention (CDC) hand hygiene guidelines. 7BManage as sentinel events all identified cases of unanticipated death or major permanent loss of function associated with a health care-associated infection.

19. National Patient Safety Goals Goal 13 Encourage patients’ active involvement in their own care as a patient safety strategy. 13ADefine and communicate the means for patients and their families to report concerns about safety and encourage them to do so.

20. Proficiency Testing What special steps are to be taken when performing Proficiency Testing?

21. Proficiency Testing Perform PT Samples the same as Patient Samples: Perform PT Samples the same as Patient Samples: –Do not run in duplicate. –Do not run additional QC. –Do not perform instrument calibration or PM. –Do not select staff. –Do not perform on additional instruments until after initial testing as been completed.

22. Patient Electronic Lab Record Review Current Department of Pathology initiative to review: Current Department of Pathology initiative to review: -All current test results electronically transmitted. -All current test results electronically transmitted. -Any new tests. -Any new tests. -Any modifications to current tests, e.g. -Any modifications to current tests, e.g. Changes to reference range Changes to reference range New CAV New CAV Modification to interpretation Modification to interpretation

23. Patient Electronic Lab Record Review Review to include: Review to include: –Correct test name –Patient identification –Name and address of testing lab –Body source, if applicable –Collection date and time (if applicable) –Test result –Units of measurement or interpretation –Comments –Finalized result date and time –Reference range –Results outside of reference range noted –CAV noted –Laboratory identification number

24. Patient Electronic Lab Record Review Systems to be Reviewed: Systems to be Reviewed: 1) BDM - Pharmacy system 1) BDM - Pharmacy system 2) Compliance+ from Salar - handheld device for selected lab results used on Medicine floors 2) Compliance+ from Salar - handheld device for selected lab results used on Medicine floors 3) EPR 3) EPR 4) Howard County General Hospital Meditech system 4) Howard County General Hospital Meditech system 5) Bayview Medical Center Meditech system 5) Bayview Medical Center Meditech system 6) Mercury MD - (future handheld device to be used in Surgery Department) 6) Mercury MD - (future handheld device to be used in Surgery Department) 7) OCIS - Oncology system 7) OCIS - Oncology system 8) Eclipsys SCM (POE) - clinician order entry system 8) Eclipsys SCM (POE) - clinician order entry system 9) QS - OB/Gyn system 9) QS - OB/Gyn system 10) Eclipsys SCC - result system used in all ICU locations at the bedside 10) Eclipsys SCC - result system used in all ICU locations at the bedside 11) Theradoc - selected lab/micro results on the Infection Control system 11) Theradoc - selected lab/micro results on the Infection Control system 12) Teleresults - (future Transplant system) 12) Teleresults - (future Transplant system)

25. Questions???