Medical Error Prevention: Patient Safety
Continuing Education Credits
Medical Error Prevention is a comprehensive course that includes potential causes of medical errors in the clinical laboratory, important legislation and definitions, and steps laboratorians can take to reduce the impact of medical errors in their workplace. This course is an ideal part of an effective medical error reduction program and is appropriate for both experienced and novice laboratorians.
Objectives
- List and describe the six aims of the National Academy of Medicine to improve the quality of health care.
- Describe the National Academy of Medicine aims within the context of quality clinical laboratory services.
- Define "total testing process" and recognize errors that could occur in each phase.
- Identify outcomes of patient safety errors with respect to clinical laboratory services.
- Discuss patient safety goals.
Course Outline
- Six Aims of the National Academy of Medicine to Improve the Quality of Health Care
- State of Quality in Health Care
- Six Domains of Quality in Healthcare as Defined by the National Academy of Medicine
- Improving Effectiveness
- Patient-centered Care and Timeliness
- Preventing Medical Errors Through Patient Involvement
- Efficiency and Equity
- According to the National Academy of Medicine, quality health care systems in the United States should be:
- One way patients and their families can become active participants in their health care is by:
- The National Academy of Medicine Aims Within the Context of Quality Clinical Laboratory Services
- Clinical Laboratory Services and Safety
- Scenario: Clinical Laboratory Services and Safety
- Which of the following options related to clinical laboratory services is unlikely to cause patient harm?
- Clinical Laboratory Services and Effectiveness
- Clinical Laboratory Services and Patient-Centered Care
- Clinical Laboratory Services and Timeliness
- Scenario: Clinical Laboratory Services and Timeliness
- Clinical Laboratory Services and Efficiency
- Scenario: Clinical Laboratory Services and Efficiency
- Clinical Laboratory Services and Equity
- Scenario: Clinical Laboratory Services and Equity
- Which of the following best defines effective clinical laboratory services?
- How might a laboratory ensure equity in laboratory testing services?
- Recognizing Errors that Could Occur in Each Phase of the Total Testing Process
- Medical Errors
- Factors Contributing to Medical Errors
- Which of the following options is an error of omission?
- Total Testing Process
- Safe Pre-Examination Component of Total Testing Process
- Scenario: Safe Pre-Examination Component of Total Testing Process
- Safe Examination Component of Total Testing Process
- Safe Post-Examination Component of Total Testing Process
- Patient-Centered Pre-Examination Component of Total Testing Process
- Scenario: Patient-Centered Pre-Examination Component of Total Testing Process
- Patient-Centered Examination Component of Total Testing Process
- Patient-Centered Post-Examination Component of Total Testing Process
- Scenario: Patient-Centered Post-Examination Component of Total Testing Process
- Identify the phase of the total testing process in which each error occurs.
- Misinterpretation of an alphabetic flag in the result field, such as using a lowercase letter L (l) to indicate a low result, where the result could be interpreted as the number 1, is an example of what type of patient safety error?
- Non-Conforming Events: Outcomes of Patient Safety Errors with Respect to Clinical Laboratory Services
- Outcomes of Laboratory Services
- The Laboratory Quality Management System and Non-Conforming Events
- Reportable Errors
- Reporting of Errors
- During coagulation testing, a reagent lot failure went unnoticed, producing falsely prolonged aPTT results. The patient was misdiagnosed with a bleeding disorder and underwent unnecessary imaging and hematology consultation before the error was discovered. What type of reportable event does this represent?
- NCEs of External Origin
- Corrections, Corrective Actions, and Preventive Actions
- NCEs of Internal Origin
- Management of Non-Conforming Events
- Identification
- Identification, continued
- Investigation
- Analysis
- Root Cause Analysis
- Root Cause Analysis, continued
- RCA Example: Cause-and-Effect Diagram
- Five Whys
- Failure Mode and Effect Analysis
- Implementation
- Verification of Effectiveness
- Verification
- Verification, continued
- Why Verification May Fail
- Communication
- Management Review
- Documentation
- True or False: The risk management department has notified the laboratory director that a physician suspects her patient’s laboratory results caused a near-miss in treatment options. Since no actual harm was done to the patient, this is not an example of a situation when an NCE should be reported.
- NCEs may be of external or internal origin. From the answer choices, choose the NCE of internal origin.
- Sources of Data to Identify Errors and Patient Outcomes
- Monitoring Laboratory Processes to Prevent Medical Errors
- Data Sources to Identify Errors
- All of the following sources may be useful for identifying patient safety problems except:
- Patient Safety Goals
- The Joint Commission 2025 National Patient Safety Goals for Clinical Laboratories
- National Patient Safety Goal: Identify Patients Correctly
- Which of the following is not an acceptable patient identifier to use prior to performing venipuncture procedures?
- National Patient Safety Goal: Improve Staff Communication
- National Patient Safety Goal: Prevent Infection Through Hand Hygiene
- What is generally considered the single most important procedure for preventing the spread of healthcare-associated infection?
- A medical laboratory technician (MLT) calls the ICU to report a critical troponin I result of 12.6 ng/mL. The nurse on the phone listens and thanks the MLT. The MLT documents the call. What was the primary error in this scenario when reporting a critical result?
- References
- References
Additional Information
Level of Instruction: Intermediate
Intended Audience: Medical laboratory scientists, medical laboratory technicians, laboratory supervisors, and laboratory managers. This course is also appropriate for MLS and MLT students and pathology residents.
Author: Garland E. Pendergraph, PhD, JD, MLS(ASCP)SM, HCLD/CC(ABB) received his MSPH from the University of Kentucky in Lexington, his PhD in medical parasitology/entomology and mycology from the University of North Carolina in Chapel Hill and his law degree with a concentration in health care law from Concord Law School, Purdue University. He also did a fellowship in Tropical Medicine at Louisiana State University School of Medicine. He is the author of a textbook on phlebotomy, a number of scientific articles, plus internet training programs. He is the director of five laboratories.
The author has no conflict of interest to disclose.
Reviewers:
Dr. Julie Ann West, PhD, MLS(ASCP)CMSMCM is certified by the American Society for Clinical Pathology Board of Certification (ASCP BOC) as a Medical Laboratory Scientist (MLS) and Specialist in Microbiology (SM). In addition, Dr. West has earned a PhD in Public Health, Epidemiology Specialization with emphasis on infectious diseases and a Certified in Public Health (CPH) certification by the National Board of Public Health Examiners. Dr. West is experienced as a technical specialist, safety officer, educator, and lead in the Veterans Health Administration healthcare system, and has prior experience as an administrative laboratory director.
Joshua J. Cannon, MS, MLS(ASCP)CMSHCM received his Bachelor of Science and Master of Science in Medical Laboratory Science from Thomas Jefferson University in Philadelphia, PA. He holds Medical Laboratory Scientist and Specialist in Hematology certifications through the ASCP Board of Certification. He was a professor at Thomas Jefferson University for seven years before transitioning into his current role as Education Developer at MediaLab by Vastian. His areas of expertise and professional passions include clinical hematology and interprofessional education.