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Moving Mountains with Patient Safety
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MOVING MOUNTAINS.... "It is the voice and actions of many that create the ripples that can
move mountains.”~unknown By: Lezlee Koch, Past ASCLS Region V Director February 2007 The mountains that now must be moved are
laboratory errors. By moving these mountains, clinical laboratory professionals will help assure patient
safety and improved medical outcomes for the patients they serve. For patients, some of the most devastating
medical mistakes can start in the laboratory, studies by the IOM and national health & safety organizations document that
3 to 5 percent of the billions of specimens taken each year are defective, be it a biopsy that doesn’t extract the tumor
cells, blood that isn’t drawn correctly, or even a mix-up with another patient’s sample.
These same studies also document that only about 1 percent of the occurring errors lead to serious harm or delays in
treatment. Even though this low percent may sound assuring, you and I both truly hope that it is not us
or one of our loved ones that are part of this percent when we seek healthcare. Clinical laboratory professionals know that tests can fail and outcomes can be impacted because
things can go wrong at every step of the process even with multiple checks and balances in place. Every
day laboratory professionals combat pre-analytical, analytical, and post-analytical errors with quality assessment mechanisms
that are second nature to us. Over the past several years, our clinical laboratories have enhanced policies
on positive patient identification, specimen labeling, handling critical values, and many more. Laboratories
have embarked on successful quality journeys utilizing Six Sigma principles and Lean production techniques with the ultimate
goal of decreasing errors and improving testing turn-around-times to improve patient outcomes. Quality
is at the heart of everything we do. So have we done enough? Absolutely not! We have remained focused on the areas within our direct control. The time
is now to step out of that mode. Clinical laboratory professionals must start pursuing quality in areas
that may not be in their direct control but absolutely do impact quality in laboratory medicine and ultimately patient safety.
These areas may be any where from correct test ordering by a physician, to patient education so they may be actively
involved in medical decisions for their care, to guiding correct medical intervention strategies through expansion of interpretive
test resulting, to assisting in developing clinical pathways that utilize appropriate and effective laboratory testing.
ASCLS Is Focusing on Patient Safety – New Patient Safety
Task Force Appointed Background:
The Institute of Medicine (IOM) study recommended that all health care organizations and professional groups “adopt
an explicit purpose to continually reduce the burden of illness, injury, and disability and to improve the health and functioning
of people.” The difference between the health care that we have now and the health care that we could
and should have is described as a chasm. The IOM suggests six aims that health care organizations and professions
should focus attention in order to improve the performance of the health care system and achieve the above
purpose. These aims are:1. Safety: focus on patient safety so that we do not harm the patients while treating them.2.
Effectiveness: provide services
based on benefit to the patient and based on evidence based practice to avoid over- and under-use of services.3.
Timeliness: reduce the time to
provide care to prevent additional harm to the patient4. Efficiency: avoid waste of medical resources5.
Equitableness: provide quality
care that does not vary according to sex, race, ethnicity, geographical location, and socioeconomic status. Your ASCLS Board of Directors has appointed a new “Patient Safety Task Force”.
Region V is well represented on this Task Force (TF). Members appointed include: Cathy
Otto (Chair), Rick Benson (MI), Judy Davis (TN), Shirley Heber (SD), Mary Jo Tietge (MN), Jean Bauer (MN), Elissa Passiment
(Staff Liaison) and myself as the Board Liaison. The TF is charged with recommending strategies that ASCLS
should adopt to address these aims and that will serve to inculcate the IOM recommendations into our mission and strategic
plan. In particular, the TF should make recommendations as to how ASCLS can help the laboratory workforce
develop and evaluate methods that focus on patient safety. The TF is requested to submit its recommendations
to the ASCLS Board of Directors for discussion at the Annual Meeting in San Diego, July 17, 2007. What Can Region V Members Do To Assist The Patient Safety Task Force?Have you, your laboratory, your facility
or your health system developed new quality assessment or safety initiatives that address one of the six aims listed above
to improve performance in health care? Do you have suggestions for development of new programs, protocols,
references, or resources to achieve improved patient outcomes and safety? If you answered yes to either
of these… we want to hear from you. You may contact anyone of the TF members or myself at lezleek@sio.midco.net. As the opening quote states, “It is the voice and action of many that create
the ripples!” We want our ASCLS ripples to turn into tidal waves… you can help make that happen!
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