All laboratory team members can contribute to the reduction of patient harm by learning about and complying with established procedures designed to standardise operations and reduce errors.

Standardisation for a purpose

About 10 years ago, Dr Grace F Indradjaja, Managing Director at Siloam Hospitals Group in Indonesia, initiated the process of standardisation with her team in an effort to reduce patient harm through the reduction of errors in the lab.

The purpose of this standardisation was multi-fold. The hospitals she served were growing rapidly. Each hospital branch was using different laboratory equipment, which resulted in diverse lab methodologies, instruments and fragmented procurement.

“To achieve patient safety and customer satisfaction, there was a need for higher quality lab service with better accuracy, reproducibility, reliability and faster turnaround time,” Dr Indradjaja says. “There was a need for a more effective infrastructure, resource planning and capacity development.” 

She and her colleagues also realised that high-performance lab equipment was required to ensure best quality of service and an integrated system was essential in order to speed up their turnaround time.

Laboratory standardisation in Dr Indradjaja’s hospital included installation of standardised equipment and the provision of refresher training for all laboratory staff. It also involved procurement of reagents using a cost per reportable result (CPRR) system to maintain the quality of reagents and improve efficiency of the procurement process.

Reducing errors extends beyond the lab into its relationships with vendors and other external partners. Developing relationships with suppliers who have the highest quality instruments, products and platforms leads to high-quality lab service and patient care.

“Our laboratories work together with vendors to maintain the quality of reagents using an Inventory Solution System to improve the procurement process, storage and control of beyond-use-date of reagents,” Dr Indradjaja. She also notes that the efficiency gained through centralisation of specific tests and the building of a referral lab system may help reduce error.

If a lab has partner branches or is linked directly to other hospital departments, the use of common technology and testing platforms can ensure standardised lab results and reference values as well as reduce turnaround time.

When mistakes happen

Of course, there are times when errors occur and effective labs must be prepared for when they do. 

“Siloam Hospitals implemented an effective incident reporting system with a ‘no blame’ culture,” says Dr Indradjaja.  

In her lab, every staff member has the authority to report an incident so that a root cause analysis can be conducted in order to improve their systems. This approach may reduce future errors and has the added benefit of contributing to a positive work culture. Dr Indradjaja believes it may even improve employee retention.

Dr Indradjaja’s lab created a strategy to reduce errors in the pre-analytic, analytic and post-analytic phases.

In the pre-analytic phase, she and her team implement International Patient Safety Goals [1] to identify patients correctly using two patient identifiers (full name and date of birth). Their laboratory information system (LIS) can print out a barcode label so that the primary sample tube can be connected directly to the patient and recognised by the equipment.

An ongoing refresher course for phlebotomists ensures proper specimen collection technique using the vacuum extraction tube system and the use of a pneumatic tube reduces transport time whilst ensuring the safety and stability of specimens. During this phase, she and her team carefully monitor expiration and beyond-use dates of all reagents and consumables.

Error reduction in the analytic phase includes quality assurance measures that encompass both internal and external quality control. Dr Indradjaja and her team take these measures to ensure that equipment and reagents are maintained in order to obtain valid results. She believes that routine preventive maintenance on lab equipment and monitoring of the temperature where reagents are stored are two key steps in reducing errors that could occur in the analytic phase.

In the post-analytic phase, Dr Indradjaja chooses equipment that can be integrated with the LIS allows test results to be automatically sent to the LIS. Patient history and cumulative results are accessible through LIS for easier monitoring of results, thus reducing or preventing errors related to data input.

Established procedures ensure safety

A focus on safety and infection control in the lab clearly reduces patient harm. Many labs establish key performance indicators (KPIs) that align with procedures to ensure teams meet strict safety standards. In Dr Indradjaja’s lab, one of these KPIs focuses on turnaround time. Her lab targets 1.5 hours for routine lab tests or 15 minutes for critical values such as haemoglobin level, platelet count and potassium level.

Upon determination of a critical value, the lab will try to notify the clinician three times. The clinician receiving the information is then required to read back the critical value and the process is documented in LIS. The clinician/ordering doctor must then document the critical value and the treatment given in the patient’s integrated notes. The readback provides an extra level of quality control and recording the process in LIS creates an audit trail allowing users to trace back issues that may have occurred and resolve them quickly.

Procedures such as these ensure standardisation across the lab and allow all team members to align their actions with established safety practices and goals.

Optimising timeliness and quality with technology

It may seem that timeliness and quality are at odds when it comes to reducing patient harm. It is the lab’s responsibility, however, to find ways to ensure their results allow patients to be treated appropriately within clinically important timings.

“Poor quality is a disaster,” says Dr Indradjaja. “It causes patient harm and is bad for our reputations in terms of patient trust, clinician trust and the whole organisation’s trust.” She added that reliable and accurate lab results are essential for correct diagnosis and treatment. Technology offers solutions that help reduce turnaround time without sacrificing quality.

To maintain the balance between timeliness and quality, the right equipment and laboratory information system are essential. Dr Indradjaja believes that an integrated and automated process is also required to reduce or eliminate manual sample handling. Lab managers can choose between a myriad of technology options to find the solution that best meets the needs of their team, their physicians and the patients they serve.

Results that are both accurate and timely can reduce patient harm and may also shorten the patient’s length of stay, thus reducing the overall patient burden and costs.

Getting the team on board

Workforce training can help team members to understand the importance of patient harm reduction. In Dr Indradjaja’s lab, training is done continuously as technology keeps evolving and specific training related to patient safety is carried out at least once a year. Product knowledge training is given every month. She believes frequent training allows her staff not only to stay current with issues affecting patient safety, but also to improve the quality of service and the subsequent validity of lab test results.

Creating a metric to measure patients’ harm allows for tracking of incidents and can also serve as an educational tool for team members.  Dr Indradjaja employs a standard risk matrix to improve patient safety (see Figure 1). The matrix considers the frequency at which an incident may occur against its potential severity in terms of visitor, staff or patient health. The matrix can also be applied to the effects of the incident on service, finance and the environment, as well as organisational, reputational or legal impacts. Placement of the incident against the matrix allows for a quick determination of the most appropriate course of action.

Ultimately, the goal of the lab is to improve patient health through quality and timely service. Error reduction through standardisation of processes, use of appropriate technologies and workforce training can improve patient health by reducing patient harm.

[1] International Patient Safety Goals, Joint Commission International