A few years ago, a pediatric patient in the intensive care unit at The Hospital for Sick Children (SickKids) in Toronto was inappropriately treated for low potassium because of a mislabelled blood specimen. Fortunately, frontline staff identified this error and the patient suffered no adverse consequences. This incident created long-lasting impact, providing an excellent opportunity for a quality improvement (QI) intervention at the hospital, which treats more than 215,000 children every year. The lessons learned following this incident made a difference. And isn’t that why we enter medicine, to make a difference?
In this situation, making a difference meant optimizing health care processes in order to recognize the potential for medical errors before these risks ever become a reality. The concepts of improving patient safety are something I studied through the Institute for Healthcare Improvement (IHI) Open School. I joined the IHI Open School Chapter at the University of Toronto shortly after starting medical school and I was fortunate to become involved with this quality improvement project at SickKids. Quality improvement work in healthcare, I learned, reflects the collective efforts of interprofessional teams, and aims to evaluate current processes, identify areas requiring improvement, and set forth initiatives to improve safety, efficiency, and overall patient satisfaction. The IHI recognizes the importance of QI skills and knowledge among young health care professionals, and provides opportunities for students of all health professions to participate in QI work through practical experiences, workshops, seminars, and online courses.
The motivation to improve
As Team Leader on the QI project at SickKids, I collaborated with the quality improvement and clinical teams, and led an interprofessional team composed of medicine, nursing, and engineering students. We aimed to reduce the rate of mislabelled specimens in the Pediatric Intensive Care Unit (PICU) and the Cardiac Critical Care Unit (CCCU) by implementing sustainable measures for preventing these errors in the future.
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Statistically, the rate of mislabelled specimens at the time of the SickKids incident was extremely low given the volume of products sent to the lab. (Providers could send more than 7,000 products to the lab in a given month.) However, each incident of a mislabelled specimen had the potential to cause devastating effects on the pediatric patient, their family, and the entire health care team. The enormous impact of a preventable error served as the primary motivator for our efforts to improve overall patient safety.
The initial step of the project involved analyzing safety reports from previous years. The monthly incidence of mislabelled specimens was more than twice the hospital target. After careful examination of the process, our team identified that the root cause of the problem was that multiple staff members were involved in the blood collection process. In order to effectively address this issue, we recognized that frontline staff engagement was vital for implementing sustainable change.
From idea to improvement
A multidisciplinary Mislabelled Specimen Team was assembled. Using input and support from frontline clinical staff, we designed the One-Person-Process (OPP) — a standardized work protocol in which the blood collection process would be carried out by one person, from start to finish. We aimed to reduce the rate of mislabelled specimens from four specimens to two within a 12-month time period, our ultimate goal being to reduce mislabelled specimen to zero.
We then transitioned to testing changes on a small scale using Plan-Do-Study-Act (PDSA) cycles, part of the Model for Improvement methodology that IHI uses to guide improvement. The PDSAs involved implementing a department-wide One-Person-Protocol education program, studying adherence to the protocol after program completion, investigating reasons for which the program did not reach 100 per cent success, and implementing changes to the patient labelling system in order to address the limitations of our protocol. Our outcome measurements in the project included the number of monthly mislabelled specimens and the frequency of blood collections using the OPP protocol. At the end of six months, the number of mislabelled specimens decreased by 50 per cent, and the frequency of blood collections successfully completed by one person increased by 32 per cent.
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This improvement project taught me that engagement of frontline staff provides a fertile climate for improving quality and patient safety. In addition, staff-driven solutions, peer-to-peer education, and ongoing evaluations are powerful tools for generating change. I plan to continue to pursue my passion for QI and patient safety at the University of Toronto as project coordinator for QI initiatives at various Toronto-based hospitals. I recently joined the QI committee for a student-run primary-care community clinic in Toronto, which focuses on addressing underserved populations. I am hoping to further develop my QI skills throughout medical school and to continuously partake in opportunities that will strengthen my ability to deliver effective care to future communities.
Where to go from here?
Attending the IHI 26th Annual National Forum on Quality Improvement in Health Care in December 2014, an international conference that brings together thousands of health care professionals, showed me that improving the patient experience, reducing medical errors, and enhancing the level of work satisfaction experienced by health care professionals serve as motivators for change all across the globe. It is not enough for students to recognize health care challenges. Students need to be empowered with the tools and support necessary to effectively address these limitations. Partaking in quality improvement education is a crucial first step towards delivering the health care changes needed for a better tomorrow.
