Vol 2, Issue 3 (November / December, 2005): Improving Laboratory Utilization (Purchase this PDF bundle)

From the Editor
Introduction to Issue
Michael Astion, M.D., Ph.D.
This month’s issue focuses on laboratory utilization as a patient safety issue.

Interview
Improving Laboratory Test Utilization
Brian R. Jackson, M.D., MS
The interview covers ARUP’s specific efforts to improve the test ordering habits of their reference laboratory clients as well as general principles regarding improving laboratory utilization.

Interview
Child Abuse or Inherited Metabolic Disorder? Tragic Consequences Associated with Underutilization of the Clinical Laboratory
Piero Rinaldo, M.D., Kimberly Hart
LEPS interviewed Ms. Kimberly Hart and Dr. Piero Rinaldo regarding cases where failure to order tests for inherited metabolic disorders leads to misdiagnosis, and false accusations of child abuse including murder.

Perspectives
Overutilization of the Laboratory, Part 1: Googling our Way into Overutilization and Misinterpretation
Michael Astion, M.D., Ph.D.
This is the first of two articles on overutilization of the clinical laboratory. The first article explores causes of overutilization and its implications for patient safety. The second article, appearing in the next issue of LEPS, discusses interventions to reduce overutilization.

Vol 2, Issue 2 (September / October, 2005): LEPS Philosophy, Preventing the Drift into Failure, and Automated Specimen Collection (Purchase this PDF bundle)

Interview
Drifting into Catastrophic Failure: Causes and Cures
Sidney Dekker, Ph.D.
LEPS talked with Dr. Dekker about one of his favorite topics: how organizations drift into unsafe conditions.

Interview
Implementation of an Automated Identification and Specimen Collection System
Lawrence Bologna, MBA, MS, Michael Mutter, MS, RPh
LEPS traveled to New Jersey for an onsite interview and hospital tour with Lawrence Bologna and Michael Mutter about their implementation of BD.id1(Becton-Dickinson, Franklin Lakes, NJ), an automated patient identification and specimen collection system.

Perspectives
What You’ve Always Wanted to Know About Laboratory Errors & Patient Safety
Michael Astion, M.D., Ph.D.
LEPS is now well into its second year of publication. The readership is growing, and by the time this issue is released, LEPS will be in more than 300 subscribing facilities. The purpose of this short essay is to outline the philosophy that guides LEPS.

Toolbox
Web-Based Resources for Patient Safety
LEPS Staff
These websites have been useful for teaching, learning, inspiration, idea generation, and -in the case of the web site about design- a good laugh.

Vol 2, Issue 1 (July / August, 2005): Patient Safety Interventions and Error Disclosure (Purchase this PDF bundle)

Case Study
Critical Value Not Called
Kerstin Edlefsen, M.D.
A relatively simple, but successful strategy is to use memory aids such as checklists and structured sign-outs3 to help physicians remember to follow through on ordered tests.

Interview
Continuous Systems Improvement, I Love Lucy, and Scraping Burnt Toast with Gary Conkle
LEPS Staff
LEPS interviewed Gary Conkle about current concepts in quality improvement. Mr. Conkle is an engineer, who has been working in the area of process improvement for more than twenty years.

Interview
Disclosure of Medical Errors to Patients with Thomas H. Gallagher, M.D.
LEPS Staff
LEPS interviewed Dr. Gallagher about the disclosure of medical errors to patients. Dr. Gallagher is an international expert on the topic and has written about it extensively.

Perspectives
Putting Power into Patient Safety Interventions (Part 2)
Michael Astion, M.D., Ph.D.
Unfortunately, the most commonly chosen interventions are the weakest, and in this article we provide some teaching aids that will help convince management and staff to move toward stronger interventions.

Vol 1, Issue 6 (May / June, 2005): Incident Reporting & Intervention Strategies (Part 2) (Purchase this PDF bundle)

From the Editor
Introduction to Issue 6
by Michael Astion, M.D., Ph.D.
This issue of Laboratory Errors and Patient Safety (LEPS) is the second of two concerned with the general topic of reporting and analyzing incidents that jeopardize patient safety.

Interview
The Just Cause with David Marx, J.D.
by LEPS Editorial Staff
LEPS interviewed David Marx, J.D. Mr. Marx is the President of Outcome Engineering, a firm that consults with hospitals, air carriers, and governments on issues related to human errors. Mr. Marx authored an influential article entitled 'Patient Safety and the Just Culture: a Primer for Healthcare Executives.'

Interview
Root Cause Analysis and Patient Safety Interventions with John Gosbee, M.D.
by Kaveh Shojania, M.D.
LEPS interviewed Dr. John Gosbee an international expert on root cause analysis and patient safety interventions to obtain an overview of these topics. Dr. Gosbee’s remarks are broadly applicable to any detailed method used to investigate adverse events.

Perspectives
Putting Power into Patient Safety Interventions (Part 1)
Michael Astion, M.D., Ph.D.
Dr. Kaveh Shojania, in the previous issue, discussed the common management error of emphasizing the logging of incident reports while putting insufficient effort into analysis and interventions. This month, Dr. John Gosbee talked about how detailed analysis of adverse events is useless if it produces shallow interventions.

Vol 1, Issue 5 (March / April 2005): Incident Reporting (Part 1)(Purchase this PDF bundle)

From the Editor
Introduction to Issue 5
by Michael Astion, M.D., Ph.D.
This issue of LEPS will give you fuller insight into incident reports and other methods of detecting clinically significant laboratory errors, and it will help you implement better methods for finding cases that fuel quality improvement in your laboratory.

Perspectives
Detecting Laboratory Errors: Incident Reporting & Beyond
by LEPS Editorial Staff
Incident reports go by a variety of names, but no matter the nomenclature they encompass both internal laboratory incident reports and formal incident reporting through the institution's risk management reporting system.

Interview
Incident Reporting Best Practices
by Kaveh Shojania, M.D.
Management will kill the morale of staff if they put all the quality improvement effort into implementing a great incident reporting system and little or no effort into interventions that improve patient safety.

Ask the Experts
Error Detection
by Linda M. Sandhaus, M.D.
Are there any innovative practices besides incident reporting you are using to detect errors?

Interview
Online Incident Reporting with Mark A. Keroack, M.D., MPH
by LEPS Editorial Staff
How do you know that the decreases in events are not just decreases in reporting the events?

Case Study
Communication Error on a Manually Diluted Specimen
by Camilla Allen, M.D., MS & Michael Astion, M.D., Ph.D.
Overall, this case can be considered a lapse in the continuity of care. Continuity errors are problematic for nearly all medical disciplines.

Vol 1, Issue 4 (January / February 2005): Postanalytic Errors (Part 2) (Purchase this PDF bundle)

From the Editor
Introduction to Issue 4
by Michael Astion, M.D., Ph.D.
We hope that this issue will help you approach clinically significant postanalytic problems from a new point of view and aid you in developing interventions that improve patient safety in your facility.

Perspectives
Notifying Physicians About Laboratory Data: Pushing and Pulling with the Help of a Sympathetic Laboratory
by Michael Astion, M.D., Ph.D. & David Chou, M.D.
Laboratory staff members are sometimes inappropriately unsympathetic to caregivers who fail to follow up on ordered tests. This reflects ignorance of the burden of pulling results.

Case Study
Troponin Postanalytic Error
by LEPS Editorial Staff
The biggest, and unfortunately most common mistake that management can make in this case is to look at the active error only, while remaining blind to the latent errors.

Case Study
Error by an Impaired Staff Member
by Andy Hoofnagle, M.D., Ph.D.
Prevention of errors by impaired employees is one of the most challenging problems for laboratory management. Management must have the courage to confront the problem.

Ask the Experts
Autovalidation with Maria Laura Chiozza, M.D., Mario Plebani, M.D. & Linda Sandhaus, M.D.
by LEPS Editorial Staff
Are there any innovative practices besides incident reporting you are using to detect errors?

Vol 1, Issue 3 (November / December 2004): Postanalytic Errors and Communication (Part 1) (Purchase this PDF bundle)

From the Editor
Introduction to Issue 3
by Michael Astion, M.D., Ph.D.
We are confident that this issue will give you a framework for creating interventions for common postanalytic errors and help improve the safety of patients at your facility.

Perspectives
Clinically Significant Errors Caused by Misrepresentation of Laboratory Data in Electronic Medical Records
by Michael Astion, M.D., Ph.D., David Chou, M.D. & James Fine, M.D.
Interfaces are not trivial to design and implement and they require sufficient time for testing and a team that has knowledge of both laboratory testing and the information systems being interfaced.

Case Study
Phone Communication Problems
by LEPS Editorial Staff
The first item to address is that phone communication of results should not be done by harried, multi-tasking employees.

Ask the Experts
Critical Value Reporting
by Jo D Fontenot, MS, MT (ASCP), Ron Weiss, M.D., M.B.A., & Paul Edelstein, M.D.
How do you overcome the problem of finding the physician or nurse who can act on a critical value? Has the 80-hour work rule for residents made it more difficult to find the correct physician?

Profile
Critical Values Reporting and Read Back
by Jane Vargas, CLS, MS
What are the reasons behind the policy decision to notify the RN rather than the physician for inpatient critical values?

Vol 1, Issue 2 (September / October 2004): Patient Identification and Specimen Collection (Purchase this PDF bundle)

From the Editor
Introduction to Issue 2
by Michael Astion, M.D., Ph.D.
It is also fitting to dedicate our first themed issue to these topics since improving the accuracy of patient identification is one of several national patient safety goals outlined by JCAHO for 2004 and 2005 (www.jcaho.org)

Feature
Specimen Collection Interventions
by LEPS Editorial Staff
Interviews with experts from several institutions revealed unique interventions that target key sources of specimen collection errors and their associated injuries.

Looking Ahead
Future Trends in Patient Identification and Specimen Collection
by Michael Astion, M.D., Ph.D.
Standardization of specimen collection procedures reduces errors by simplifying, optimizing and reducing the number of collection procedures followed in a healthcare organization.

In the News
Patient Safety Issues
by LEPS Editorial Staff
Senate passes patient safety bill with new error reporting system.

Perspectives
Decentralized Specimen Collection and Patient Safety
by LEPS Editorial Staff
For institutions employing a significant amount of both centralized and decentralized phlebotomy, the responsibility for specimen collection can vary by location, shift, collection procedure, patient type, as well as by test priority.

Interview
Decentralized Specimen Collection and Patient Safety
by Error Reduction and Risk Assessment with Shirley Weber, MHA
All labs should benefit from implementing a restrictive specimen acceptance policy as well as policies specific to patient identification for clinical care and treatment utilizing a minimum of two patient identifiers.

Case Study
Mislabeling in the Hospital
by LEPS Editorial Staff
The interventions aimed at nursing staff should address both educational deficits and the possibility that the nurse was taking a short cut.

Vol 1, Issue 1 (July / August 2004): Introduction to Laboratory Errors & Patient Safety (Purchase this PDF bundle)

From the Editor
Introduction to Issue 1
by Michael Astion, M.D., Ph.D.
The need to look beyond the lab to grasp the impact that lab errors have on patient care, as well as the need for effective interventions, requires a concentrated effort from the laboratory community to share concrete experiences and collective wisdom.

Feature
Creating a Culture of Patient Safety
by Michael Astion, M.D., Ph.D.
Laboratory leaders must expand their error reduction strategies to confront issues of patient safety.

Case Study
Microscopy Error in the Microbiology Laboratory
by LEPS Editorial Staff
Significant and/or rare parasites should be reviewed by bench staff regularly, and documented.

Best Practices
Error Factors in the Hematology Laboratory
by Linda M. Sandhaus, M.D.
Many errors occur at the first decision point: determining whether to verify an abnormal numeric result without further evaluation.

Interview
Errors in the Hematology Laboratory with Linda M. Sandhaus, M.D.
by LEPS Editorial Staff
Automation and health care economics have made cross-training of technologists essential to meet staffing needs in many clinical laboratories.

Ask the Experts
Who is to Blame?
by LEPS Editorial Staff
Even with process improvements and extensive re-training, some technologists seem to be repeating the same mistakes. When do you blame the system, and when do you blame the person?

Toolbox
Laboratory Incident Tracking Checklist
by LEPS Editorial Staff
A guide for investigating cases of actual or potential adverse events due to laboratory errors.