Sarah Beatty, MHSA, MLS(ASCP)CM, and Doryan Redding, ASCLS Patient Safety Committee Members

2019 was a busy year in patient safety. It saw new innovations in technology and practice as providers, health centers, and organizations move toward thinking of patients as more than just a number. Instead, patient safety initiatives, such as patient-centered care and personalized medicine, are becoming prioritized in hospital strategies because they demonstrate better health outcomes, quality scores, and cost-efficient care. The ASCLS Patient Safety Committee provides original content related to our profession that prove these exact points.

Last year this committee published 72 blog posts on ASCLS Connect through the Patient Safety and Healthcare Quality Community. In this article, we have assessed the best articles and resources from 2019 for ASCLS members who may not know about the latest information related to patient safety. We hope that by reading this you are inspired to help promote this shared purpose.

We divided the posts from the community into four categories: Provider Information (11), Policy Updates (16), New Resources and Innovation (14), and Choosing Wisely/Other Best Practices (31). Below read the one article per category that we chose to highlight as the best posts of 2019.

“Staying informed regarding patient safety initiatives is important because when medical errors occur, they not only have an impact on patients, but also on the medical professionals who make them.”

Provider Information
Advocate Excellence – ECRI’s Top 10 Patient Safety Concerns for 2019
The Emergency Care Research Institute (ECRI) released a list of the topics they see as the top challenges to the advancement of patient safety in the healthcare environment. Some of these concerns were on specific incidences, such as the recognition of sepsis or infections from incorrectly inserted IV lines. However, a majority of them spoke to the heart of the problems our committee is trying to address, such as patients’ insistence on receiving antibiotics, leading to overprescribing; burnout of health professionals; lack of development in training for high-risk situations; and standardizing patient safety efforts.

Furthermore, this article provided a detailed analysis on why these concerns should be taken seriously and suggested corrective action that could implement systemic change. Things like providers asking specific questions before prescribing antibiotics; centering on patient goals for treatment; and implementing simulation training for high-risk situations are just a handful of the great ideas that need to continue being generated to help propel our profession to new heights.

Policy Updates
Advocate Excellence – Using Informatics to Classify Sepsis for Better Outcomes
In 2019, University of Pittsburgh School of Medicine researchers used a machine learning algorithm to analyze 29 clinical variables found in the EHRs of over 20,000 UPMC patients recognized to have acute sepsis. This data concluded that by utilizing these new laboratory assays, the profession may now be better equipped to specifically relate individual cases with the treatment of best fit.

Today, informatics plays a large role in providing patients with quality care by generating both precise and accurate results to the most specific degree. One may say this is a significant increase in the way standard healthcare procedures are conducted. Yet, it also begs the question of whether or not current medical staff are competent at levels suited for allowing these processes to work to the best of their ability. With technology constantly on the rise, should laboratory education be putting a new emphasis on keeping up with the latest innovations in our field?

Regardless of the answer, we must recognize we are living in an age where procedures and policies, with regard to technology, are ever changing and evolving to ensure patients are provided with the best possible outcomes; in this case, pertaining to recognizing conditions and implementing treatment.

New Resources and Innovation
Advocate Excellence – Improving Diagnosis in Medicine (Diagnostic Error Change Package)
This article serves as a single point of strategy for executives, quality leaders, and managers for integrating patient safety into each aspect of daily operations. As medical laboratory professionals, we strive to advocate for clinical initiatives to protect patient safety and this package encapsulated it perfectly. The patient stories tug at your heartstrings while the toolkit provides detailed means by which patient safety can be ensured at any level.

One example is creating an anonymous feedback tool to alert providers and leadership to potential diagnostic issues or when testing is contraindicated or unnecessarily duplicated. Another example suggests instituting a metric for tracking laboratory errors that can contribute to diagnostic error and implementing tools to better perform information handoffs. Working with management to adjust shifts to ensure overlap would preserve the continuum of care for necessary information and complicated cases. Additionally, having an open discussion on root cause analysis, the process, and structural issues that led to the error to encourage a culture of safety and promote reporting of issues and errors.

Choosing Wisely and Other Best Practices
Advocate Excellence – Half of Hospital Infections Could Be Prevented with Proper Protocols
One of the reasons why patient safety is a cause for concern is because standard protocols are not being practiced uniformly. This results in poor outcomes for patients, which contradicts the goal of health professionals. Resources like the Choosing Wisely initiative, have been helpful in bridging dialogue between physicians, laboratorians, and patients about the risks and benefits of certain tests, treatments, and procedures. The data in this article exemplifies the need for that kind of communication.

As medical laboratory scientists, we are in a position to both alert and help other health professionals when we see best practices are not taking place. These kinds of discussions can lead to better shared decision-making in facilities to try and combat these kinds of systemic issues.

Another study conducted this year revealed diagnostic error accounts for one-third of malpractice claims. These errors were often attributed to mistakes in clinical judgement from physicians. With that knowledge, it should be clear there is still a lot of work to be done to reform healthcare practices. Visibility is always something our profession is striving to achieve. Perhaps with the recognition of this study and the data it provided, physicians and other healthcare providers may better understand the need for quality improvement.

The ASCLS Patient Safety Committee is instrumental in assuring the standard for a good healthcare community. Staying informed regarding patient safety initiatives is important because when medical errors occur, they not only have an impact on patients, but also on the medical professionals who make them. By reading through these blogs and recognizing all the hard work being done to create an environment where team members feel safe to report mistakes and learn from them, we are equipping the next generation of medical laboratory professionals with the knowledge they need to protect patient well-being.

Sarah Beatty is president and CEO of Improvement Intelligence in Brighton, Michigan.

Doryan Redding is a clinical laboratory science student at Texas State University in San Marcos, Texas.