APPENDIX 2: Case Study

Background/Facility Information

– 150-bed rural hospital

– ED utilizes contracted physicians for coverage

– ED Blood Specimen Collection: performed by ED staff (patient care techs and nurses)

– Laboratory Department: performs high complexity testing with an extensive test menu; 24/7 coverage

Performance Problem Identification

Suspected Problem Reported and Source:

– Laboratory received formal complaint from one of the newer contracted physicians

– Complaint: unacceptable laboratory testing turnaround time is causing delayed diagnosis, delayed treatment, and is negatively impacting the flow of patient admissions

– Two specific patients’ names were documented

 

Actions Taken in Response to Complaint:

– Immediate review of the documented patients’ records was completed

– Delayed testing results were confirmed; records documented that both patients had rejected specimens that required specimens to be redrawn

– A brief review of all patients seen in the ED in the last 10 days was completed to determine if the two patients were isolated cases. Review results:

• 100 patients received ED services that required laboratory testing
• 15 of the 100 patients had documented rejected specimens (15% of the patients were impacted)
• 400 total specimens were received from the 100 patients; 45 specimens of the 400 were documented as specimen rejected and required redraws (11.3% rejection rate)
• Reasons for rejection included: specimen integrity (hemolysis) (35), specimen labeling error (7), specimen not received (3)
• Laboratory leaders met with ED physicians and nursing staff.
  • It was determined that an 11.3% rejection rate was negatively impacting patient outcomes
  • It was decided to implement a Patient Safety initiative to “decrease the ED specimen rejection rate to <2%”
  • Laboratory designated as the lead department for the initiative and would include appropriate representation of ED physicians, nurses, and patient care techs
  • Laboratory proceeded to develop the “Patient Safety Indicator” to be used in the initiative

Patient Safety Indicator – Title & Form

Delayed Test Results Due to Specimen Rejection:

– Refer to “Patient Safety Indicator example form”

Indicator Metrics & Generalized Plan/Do/Study/ Act (PDSA) Information

– 10-Day Snapshot Rejection Rate: 11.3%

 

– 2-Month Baseline Assessment:

• November 2020 Rejection Rate: 10.5%
• December 2020 Rejection Rate: 10.9%
• Improvement Actions: No change actions were implemented during baseline assessment
  • Processes were evaluated (specimen collection and transport)
  • Areas for improvement were identified (e.g., education on specimen collection, handling, transportation would be completed for four new employees, education would be provided for all staff to decrease the # of line draws that were being performed

 

– January 2021 Rejection Rate: 7.0%

• Specimen rejection occurrences were reviewed, and improvement actions identified and implemented
  • Two new ED staff members since December 2020; specimen collection and handling errors again noted
  • It was noted that non-laboratory staff was responsible for new ED staff orientation and training
  • Specimen collection and handling training and competency process reviewed and updated
  • It was decided that laboratory staff would begin performing new ED staff specimen collection, handling, and transport orientation and training beginning February 2021
  • Monthly competency assessments by observation were implemented

Indicator Metrics & Generalized Plan/Do/Study/ Act (PDSA) Information

– February 2021 Rejection Rate: 6.5%

• Specimen rejection occurrences and competency assessment outcomes were reviewed, and improvement actions identified and implemented
  • Specimen handling and transport errors by multiple staff noted
  • Education on specimen handling and transport was provided for all specimen collection staff

 

– March 2021 Rejection Rate: 4.0%

 

– Refer to “Patient Safety Indicator Tracking & Graph Example”

(Note: Process, staff performance and specimen rejection reviews continue, improvement actions are implemented, and the indicator requirements continue until target is reached and maintained)