1. The Science of Patient Safety: Longitudinal Studies in an Environment of Change. Wagar EA, Hilborne LH, Yasin B, Tamashiro L, and Bruckner DA. UCLA Healthcare and Department of Pathology & Laboratory Medicine, David Geffen School of Medicine at UCLA

2. Patient Identification Safety Initiative November, 2002, reviewed all types of specimen errors and created categories Consulted with nursing, physicians, laboratory professionals Began collecting continuous data

3. Specimen Error Information: Categories Clotted specimen Container leaking Duplicate order Hemolyzed specimen Improperly collected Improperly handled Mislabeled specimen Quantity not sufficient Requisition mismatch Specimen not suitable for test Tube overfilled Tube underfilled Unlabeled specimen

4. Methods Baseline data collect 11-02 through 3-03 Critical patient identification categories targeted Three patient safety initiatives implemented at 4, 10, and 14 months Statistical analyses by paired student’s t-test and linear trend analysis

5. Three Critical Patient Identification Errors Specimen/requisition mismatch Unlabeled specimens Mislabeled specimens (“wrong blood in tube”)

6. Three Patient Safety Initiatives Phlebotomy service reorganization and education: 4 months Electronic event reporting system: 10 months Automated processing system: 14 months

7. Total Errors by Category (4-03 through 2-05)

8. Patient Identification Errors

9. Patient Identification Errors: ICUs

10. Patient Identification Errors Critical identification errors were 12.0% of all specimen errors Over 4.29 million specimens and 2.31 million phlebotomy requests Critical identification errors are <0.1% of all procedures or all specimens Patient identification errors occurred frequently in ICUs

11. Longitudinal Data: Patient Identification Errors

12. Error Specimen Category P-Value Mislabeled Specimens0.014 Requisition Mismatches0.001 Unlabeled Specimens0.002

13. Other Things that Happed Along the Way………. Outside consultant, November 2002 JCAHO, April, 2004 Departure of the outside consultant, June, 2004 New CEO appointment, July, 2004 No significant changes in trends over the period March, 2003, through February, 2005

14. Conclusions Critical patient identification errors can be decreased in an environment of change: Leadership commitment! Expensive IT solutions are helpful but not essential as change factors Awareness is a key factor for change Changes were sustainable (April, 2003, to February, 2005)

15. Patient Safety Paradigm for Change AWARENESS NOISE SUSTAINABILITY

16. THANK YOU THE UCLA PATIENT SAFETY TEAM