Presentation
PS6 - Common causal factors of lost specimens: A case for meta-analysis of RCA work products
DescriptionIntroduction
Lost specimens are unfortunate occurrences that can have a wide range of impacts on patient safety—from delaying necessary treatment to requiring repeat surgery. The limited research that exists on medical error involving lab specimens suggests that the majority of errors happen in the “pre-analytical” phase before the specimen arrives at the lab in which it will be processed (Hammerling, 2012; Lippi & Guidi, 2007). These pre-analytical specimen errors include mislabeling the specimen at the point of collection, collecting specimens into the wrong container, and losing the specimen during its transport from the point of collection to the lab. As health systems continue to shift lab work off-site to save costs, the logistics of the pre-analytical phase become more complex increasing the potential for error. Thus, it is critical to patient safety to understand what contributes to the loss of a specimen such that those contributing factors can be designed out of the system. This study describes the meta-analysis of a health system’s previously completed root cause analyses (RCAs) of serious safety events (SSEs) involving lost specimens.
Methods
This study was conducted in an 18-hospital health system located in Pennsylvania and New Jersey. The health system consists of 3 regions that all follow a standard approach for evaluating serious safety events.
Data analysis. Contributing factors from previously conducted RCAs relating to lost lab specimens were compiled and reviewed for common categories. Contributing factors were categorized by where they happen in the process of collecting, transporting, and receiving the specimen. Additionally, contributing factors were coded by work systems element using the Systems Engineering Initiative for Patient Safety (SEIPS) 2.0, i.e., person, tools and technologies, tasks, organization, and physical environment. A contributing factor could be coded as multiple work system elements.
Results
Contributing factors. In total, there were 32 contributing factors identified across the 9 RCAs. In our analysis, we identified 10 categories of contributing factors over four process domains. These included (1) ordering, collecting, and labeling specimens which included the categories: (1.1) placing and canceling orders for specimens and (1.2) labeling specimens, (2) transport to lab which included: (2.1) scanning the specimen during transfer to the lab and (2.2) leaving the specimen in the lab, (3) within the lab which included: (3.1) ensuring the specimen is received by the lab, (3.2) lab processes, (3.3) lab space, (3.4) lab staff, and (3.5) inter-lab transfer, and (4) overall process which included (4.1) the policy/system for transferring specimens.
Work system elements. Over the 32 contributing factors, there were 63 work system element associations. Each work system element was represented, though contributing factors were most frequently associated with the organizational element (21 associations as compared to 11 for person, 12 for task, 15 for tools and technology, and 4 for physical environment). Notable interactions between work system elements included the interaction between tasks and tools and technologies, e.g., the poor usability of the electronic health record (EHR) (technology) for placing or canceling a specimen order (task), and the interaction between tasks and organization, e.g., a culture (organization) of bypassing scanning the specimen during transport (task).
Discussion and Conclusion
By conducting a meta-analysis of previously conducted RCAs, we identified common causal factors to lost specimens. Further, we identified the distinct, yet overlapping work systems involved in the process of collecting, transporting, and processing a specimen, i.e., the work systems of the person/people (A) collecting the specimen, (B) transporting the specimen from the site of collection to the lab, (C) receiving and processing the specimen at the lab, and (D) for certain specimens, transferring the specimen from one lab to another. This resource-efficient approach can point patient safety teams toward the work system interactions that may be most likely to contribute to harm. Further, a meta-analysis of previous RCAs can be an opportunity to assess the quality of those RCAs.
Hammerling JA. A review of medical errors in laboratory diagnostics and where we are today. Lab Med 2012;43:41-44.
Lippi G, Guidi GC. Risk management in the preanalytical phase of laboratory testing. Clin Chem Lab Med. 2007;45(6):720-7.
Lost specimens are unfortunate occurrences that can have a wide range of impacts on patient safety—from delaying necessary treatment to requiring repeat surgery. The limited research that exists on medical error involving lab specimens suggests that the majority of errors happen in the “pre-analytical” phase before the specimen arrives at the lab in which it will be processed (Hammerling, 2012; Lippi & Guidi, 2007). These pre-analytical specimen errors include mislabeling the specimen at the point of collection, collecting specimens into the wrong container, and losing the specimen during its transport from the point of collection to the lab. As health systems continue to shift lab work off-site to save costs, the logistics of the pre-analytical phase become more complex increasing the potential for error. Thus, it is critical to patient safety to understand what contributes to the loss of a specimen such that those contributing factors can be designed out of the system. This study describes the meta-analysis of a health system’s previously completed root cause analyses (RCAs) of serious safety events (SSEs) involving lost specimens.
Methods
This study was conducted in an 18-hospital health system located in Pennsylvania and New Jersey. The health system consists of 3 regions that all follow a standard approach for evaluating serious safety events.
Data analysis. Contributing factors from previously conducted RCAs relating to lost lab specimens were compiled and reviewed for common categories. Contributing factors were categorized by where they happen in the process of collecting, transporting, and receiving the specimen. Additionally, contributing factors were coded by work systems element using the Systems Engineering Initiative for Patient Safety (SEIPS) 2.0, i.e., person, tools and technologies, tasks, organization, and physical environment. A contributing factor could be coded as multiple work system elements.
Results
Contributing factors. In total, there were 32 contributing factors identified across the 9 RCAs. In our analysis, we identified 10 categories of contributing factors over four process domains. These included (1) ordering, collecting, and labeling specimens which included the categories: (1.1) placing and canceling orders for specimens and (1.2) labeling specimens, (2) transport to lab which included: (2.1) scanning the specimen during transfer to the lab and (2.2) leaving the specimen in the lab, (3) within the lab which included: (3.1) ensuring the specimen is received by the lab, (3.2) lab processes, (3.3) lab space, (3.4) lab staff, and (3.5) inter-lab transfer, and (4) overall process which included (4.1) the policy/system for transferring specimens.
Work system elements. Over the 32 contributing factors, there were 63 work system element associations. Each work system element was represented, though contributing factors were most frequently associated with the organizational element (21 associations as compared to 11 for person, 12 for task, 15 for tools and technology, and 4 for physical environment). Notable interactions between work system elements included the interaction between tasks and tools and technologies, e.g., the poor usability of the electronic health record (EHR) (technology) for placing or canceling a specimen order (task), and the interaction between tasks and organization, e.g., a culture (organization) of bypassing scanning the specimen during transport (task).
Discussion and Conclusion
By conducting a meta-analysis of previously conducted RCAs, we identified common causal factors to lost specimens. Further, we identified the distinct, yet overlapping work systems involved in the process of collecting, transporting, and processing a specimen, i.e., the work systems of the person/people (A) collecting the specimen, (B) transporting the specimen from the site of collection to the lab, (C) receiving and processing the specimen at the lab, and (D) for certain specimens, transferring the specimen from one lab to another. This resource-efficient approach can point patient safety teams toward the work system interactions that may be most likely to contribute to harm. Further, a meta-analysis of previous RCAs can be an opportunity to assess the quality of those RCAs.
Hammerling JA. A review of medical errors in laboratory diagnostics and where we are today. Lab Med 2012;43:41-44.
Lippi G, Guidi GC. Risk management in the preanalytical phase of laboratory testing. Clin Chem Lab Med. 2007;45(6):720-7.
Event Type
Poster Presentation
TimeMonday, March 254:45pm - 6:15pm CDT
LocationSalon C
Digital Health
Simulation and Education
Hospital Environments
Medical and Drug Delivery Devices
Patient Safety Research and Initiatives