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Reducing blood collection errors in our emergency departments

Reducing blood collection errors in our emergency departments

What is a blood collection error?

Blood collection errors fall into two groups:

  1. Accuracy of information:  errors made in the patient identification process and/or documentation process.
  2. Specimen integrity:  errors made in the process of drawing the blood and transferring into tubes for processing.

Value: Better, Best, BrilliantWhy does this matter?

  • Patients may have to have another blood test.
  • Possible delay in diagnosis and/or treatment.
  • Risk of misdiagnosis or misleading/incorrect results.
  • Additional cost.

What are we trying to achieve?

Our laboratories and blood bank receive an average of 32,695 blood test requests per month of which an average of 309 cannot be processed due to collection errors. While our error rate is under 1%, which is world class, our Emergency Departments (ED) generate a disproportionate 68% of all errors.

The project team’s task was to understand why there was such a high error rate within the Emergency Departments and work with the teams to come up with solutions to significantly reduce the error rate.

Our Aim:  Reduce our blood collection errors by 70% over 12 months


What did we find?

The project team focused on the top 5 error types:

What we found

 

What have we done?

Implementation of a measurement system

This improvement was designed to increase visibility and ownership of:

  1. definition of what constituted an error
  2. the details of which errors were being made by which departments

The measurement system was designed to create clear and accurate reporting which was distributed to each department on a monthly basis.  This allowed each area to gauge their progress and identify targeted areas for improvement.

Waitemata DHB level reporting

Errors are reported at an organisational level by error type for the month (see tables below left) and the performance across the year (see graphs below right)

WDHB level reporting

Ward level reporting

Individual ward performance is also reported on a monthly basis so that specific areas for improvement can be closely monitored.

Ward level reporting

Initiatives Implemented

  • Lanyard cards were provided to all staff to support updated education packages and perspex was put on top of phlebotomy trolleys to allow posters to be displayed on key topics.
    Lanyard cards
  • Staff surveys were created at the results publicised to create friendly competition between hospital sites and between doctors and nurses to help increase knowledge.
    Staff survey results
  • Competitions were held to generate improvement ideas from staff and provide them the opportunity to champion the implementation of their ideas.
    Prizes
  • The Laboratory Request Form was updated with visual reminders, colour coding to match laboratory tests with collection tubes, and frequently requested tests were grouped under coloured headings matching collection tubes.
    Lab Request Forms
  • Nursing induction and ongoing training modules were reviewed for venipuncture[1] and cannulation[2] to ensure they were up to date and focused on key areas for improvement
  • Ensured blood bank and general laboratory request forms are permanently stored on phlebotomy trolleys[3] to avoid staff having to walk away from the patient to complete their work
  1. Venipuncture:  The puncture of a vein as part of a medical procedure, typically to withdraw a blood sample.
  2. Cannulation:  The insertion of a cannula or tube into a vein, typically to provide fluids or pain relief.
  3. Phlebotomy Trolley:  A trolley that has all the equipment required for venipuncture and cannulation, e.g. sterile swipes and needles. The trolley is on wheels so that it can be taken to the patient bedside.

We also investigated the following potential solutions:

  1. Putting an indicator on the Electronic Whiteboard system that nurses and doctors use to manage their patients, to highlight a sample is unable to be processed.
    Decision:  Not implemented due to conflicting priorities 
  2. Extending the phlebotomy service to cover the Emergency Department (ED).  The analysis showed that this service would reduce the ED error rate from 4.6% to 2%, 99 less errors a month, and the overall Waitemata DHB error rate from 1% to 0.3%, which would achieve the project goal.
    Decision:  Not implemented due to resourcing issues

Did we make a difference?

The majority of improvement effort was focused on North Shore Hospital’s Emergency Department:

General laboratory and blood bank specimen errors

Over the 12 months of improvements, the overall error rate dropped from 145 to 112 - a 23% reduction.  The Waitakere ED error rate also reduced by 10%.