NQF endorses practices for safe lab medicine
Focus is on processes that occur before, after testing
The National Quality Forum (NQF) has endorsed a set of practices to improve the safety and quality of laboratory services. Past quality improvement efforts, notes the NQF, have focused on the analytic phases of laboratory testing, but very little quality improvement has focused on the pre-analytic and post-analytic phases of laboratory testing. The need for such a focus is clear, says the NQF, because "evidence indicates that errors occur during this time at uncommonly high rates — pre-testing error rates are as high as 75%, and post-testing error rates are as high as 31%."
"One example of a pre-testing error would be a specimen mix-up," offers Paul Valenstein, MD, director of clinical microbiology and quality management at Saint Joseph's Mercy Hospital in Ann Arbor, MI, and co-chair of the steering committee that enumerated these practices. "We perform a perfect analysis with an extremely accurate result, and it's on the wrong patient because the tube was mislabeled."
An example of a post-analytic error, says Valenstein, would be having a urine culture result become available after the patient has been discharged. "The report goes to the hospitalist, who ignores it because the patient has been discharged, and the outside physician never sees it," Valenstein suggests. "Again, you have a perfectly good result — not going to the caregiver who needs it." Avoiding such errors, he says, "is all about communication and defining expectations — inputs and outputs."
The newly endorsed practices focus on communication and safety specifically within these areas and are intended to help labs adopt a more standardized approach for pre- and post-testing and thus provide safer and higher-quality care. The practices are:
- Laboratory Leadership — Leaders of organizations that participate in test ordering and leaders of clinical laboratories should collaboratively ensure that specific expectations regarding communication to and from the laboratory are met.
- Patient/Specimen Identification — Standardized policies, processes, and systems should be implemented to ensure the accurate and legible labeling of laboratory specimens.
- Sample Acceptability — Collection and processing facilities should ensure that acceptable specimens are collected using appropriate techniques.
- Test Order Accuracy — Organizations should implement systems to ensure that all test orders are accurately communicated to laboratory staff in a timely manner.
- Verbal Communication — For verbal or telephonic reporting of critical test results, verify the test result by having the person who is receiving the information record and read back the complete test result.
- Critical Value/Result Reporting — Communicate critical laboratory results to the individuals who require them and appropriately document them in a secure, confidential, accurate, and timely manner.
Keys to implementing practices
For each of these practices, says Valenstein, the NQF has general expectations as to what should be done, although each facility will customize them to fit their unique needs. So, for example, for practice #1 (lab leadership), "What we are trying to say here is if you need to communicate — and you do — and if there is not a specific industry standard, you have to know who is supposed to do what," he explains. "You need to establish whose job it is to figure out if blood ever got drawn; if the order reached the lab but was never collected: Who keeps track of that?"
Communication is a two-way street, he continues, noting that "there is not a great industry standard on who should make sure every order is followed up on."
In the outpatient setting, he says, "We feel it is the responsibility of the ordering physicians to be sure you get results for every order." However, he continues, "In the inpatient setting it's not so simple." In his facility, he says, the lab monitors every order that comes in. "If the specimen does not arrive, we notify the nursing station," he explains, adding that the nursing station could perform the function just as well. "You just have to make sure the ball is not dropped," he says.
A good place to start, Valenstein adds, is standardizing read-backs. However, he says, that is just "a very narrow part of the problem." The bottom line, he says, is that "you must recognize that communication is a problem that can't be solved only within the lab; both sides need to be responsible."
Standardizing patient/specimen identification
When it comes to identification, says Valenstein, "As a general rule if you want it done right, you have to make the system redundant." However, he adds, it's critical to pay attention to the details. "The Joint Commission, for example, has said you need two identifiers on every specimen," says Valenstein. "But you could put two identifiers on the label and then put the label on the wrong container." One solution, he says, is to always label specimens in proximity of the patient. "That means, ironically, that the purchase of a bar-code system could be worse than having a cheaper printer placed in every patient's room," he notes.
Another system involves "check digits," a system that credit card companies use that enables them, for example, to determine the credit card number using the last number on the card and employing an algorithm. The bottom line, Valenstein says, is "you can't rely on human vigilance. That will only get you to 98% or 99% accuracy."
A key issue to remember about practice #3, says Valenstein, is that the cost of a contaminated sample is considerable. "In the lab it's only $20 or $30," he says, "but it can cost the hospital considerably more because the patient will be given antibiotics they otherwise would not have needed, and their stay is longer."
Effective interventions, he continues, include providing feedback about individuals' contamination rates as well as those of the different departments in the hospital. In fact, he says, in his facility "we have a competition among the units to see who can be the best."
Accuracy is a challenge
Test order accuracy can be challenging, Valenstein concedes. "Sometimes the order the doctor writes is not the order the lab gets; for example, there are errors in reading others' writing," he notes. "Some thought direct physician order entry would solve that, but when you get to weird or esoteric tests, it can sometimes make things worse if you don't put in 'help' screens."
The problem, he says, is "there are about 6,000 different tests, and nobody can keep them all in their heads." If unusual testing is needed, Valenstein suggests "the old system where you call up the lab or pathology and ask what works best. [Computerized physician order entry] in the main is a good thing, but it's not a panacea. The system that works the best is to have someone check the paper requisition against the computer orders."
TJC has impact
The Joint Commission has a significant impact when it comes to the final two practices, Valenstein says. The verbal communication practice, for example, directly reflects the commission's "read back" guidelines.
Critical value/result reporting is a little more complicated, says Valenstein. "The Joint Commission invented a new concept — the critical test — that I am not a fan of," he says. "There is no guidance on what is to be considered critical."
In addition, he says, "It can be surprisingly difficult for people in the lab to know who to call. If they call a nurse, which is most common, she has to turn around and call the doctor." In short, he says, "Standards need to be developed by the NQF or preferred practices have to be defined and processes in place to make it clear who is caring for the patient. When patients are discharged, for example, they are more often than not cared for by a different physician. Doctors also go on vacation. So, if it's a critical result, it's not always obvious who to give it to." Having a process for identifying that person is all the more important, Valenstein says, because "failure to find that person is the cause of many malpractice cases."
[For more information, contact:
Paul Valenstein, MD, Director of Clinical Microbiology and Quality Management, Saint Joseph's Mercy Hospital, Ann Arbor, MI. Phone: (734) 712-4081.]
The National Quality Forum (NQF) has endorsed a set of practices to improve the safety and quality of laboratory services.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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