Healthcare Consulting Services
Healthcare Consulting Services with a Focus on Patient Safety Solutions and Quality Improvement Across the Health Care Continuum. Your Patient Safety Resource Solution.
September 27, 2016
Lab Errors Costly
In our multiple columns on errors related to lab testing we’ve usually focused on the cost in human terms. But there is also a cost in financial terms. With results similar to prior studies, an ECRI Institute “Deep Dive” in 2014 (ECRI Institute 2014) showed 74% of lab errors occurred in the pre-analytic phase and 22% in the post-analytic phase. Only 4% occurred during the analytic phase.
A prior study (Green 2013) estimated that errors related to poor blood specimen quality and pre-analytical errors could represent as much as 0.23% to 1.2% of total hospital operating expenses. Extrapolated to an average 650-bed hospital the unnecessary expenditure could be $1.2 million per year. Costs include those related to patient management, redraws, lab investigations, collection consumables, and instrument downtime.
A new study (Atwaru 2016) has also quantified some of the costs related to lab errors, particularly those related to the pre-analytical phase where most lab errors occur. Atwaru and colleagues noted the most common errors in the pre-analytical phase were specimen labeling errors, improperly collected samples, wrong blood in tube, and missing specimens and subsequent redraws so they focused their cost analyses on these categories of pre-analytic errors.
Factoring in the time spent by various personnel when a specimen is missing, they found the average cost of a missing specimen that is found is $401.25 and that of a missing specimen not found $583.72. But when calculating the average costs times the frequency of such events they found the average cumulative costs over 3 months were $14,826.45 and $20,430.20 for those two categories respectively.
For an improperly collected specimen with request for stat retesting the average cost was $158.30 (cumulatively $2374.50 over 3 months). And for wrong blood in a tube the average cost was $562.65 (cumulatively $11,815.65 over 3 months).
These cost estimates do not even take into account the indirect costs that might be associated with unhappy customers impacted by the lab errors.
The authors note that addressing such errors involves a broad range of personnel (client services, clerical staff, sales staff, technical staff, quality improvement staff, and executive staff).
A study on pre-analytic errors (Kaushik 2014) categorized such errors in 3 phases:
We addressed specimen labeling errors in several previous columns (see our Patient Safety Tips of the Week for October 9, 2007 “Errors in the Laboratory“ and November 16, 2010 “Lost Lab Specimens”). Another recent study looked at specimen labeling errors in specimens drawn by nurses in two adult ICU’s (Martin 2015). The error rate prior to interventions was 1.31 errors per 1000 specimens. The intervention was two-fold: (1) one-on-one education for the nurses and (2) removal of an electronic option that allowed bypassing of the barcode safety function. After the intervention the error rate was reduced to 0.139 errors per 1000 specimens. Though the actual total numbers of errors were small (10 errors before and 1 error after the intervention) the reduction was statistically significant.
Note that workarounds that bypass barcoding are not uncommon. In our June 17, 2008 Patient Safety Tip of the Week “Technology Workarounds Defeat Safety Intent” we highlighted a study by Koppel and colleagues that found 15 types of workarounds and 31 types of causes for the workarounds in barcoding medication administration systems (Koppel 2008).
In our March 6, 2012 Patient Safety Tip of the Week ““Lab” Error” we suggested each hospital (or other healthcare facility) use a tracer methodology to determine which steps in their facility might be vulnerable to errors in the pre- and post-analytic steps. It’s worth repeating here the steps we’d recommend in doing a tracer on laboratory testing:
Step 1 Choose a Test to Trace
Where would you start? Which tests should you look at? One option would be to take a look at your highest volume tests, since statistically most errors in the loop would occur for these tests. However, you might also consider looking at tests you already know may be “abused” or of controversial value. Or you might look at tests for which errors would be likely to have the most serious patient consequences.
Step 2 Ordering the Test
After you choose a test on which to run a tracer, let’s start at the beginning: the ordering of the test by a clinician. Is the rationale for ordering the test clear from the medical record? Is it for diagnosis related to current patient symptoms? Is it for screening or risk factor management? Is it a necessary follow up to a prior abnormal test result? Is it for monitoring treatment (eg. serum drug levels) or assessing for treatment efficacy or side effects?
But there are other questions you should ask. Was there a prior result of that test that might have sufficed? Was that result known? Could it have been known? Was that result available on the hospital IT system or the regional RHIO? Did the provider attempt to see if a prior result was available?
If the rationale for the test is not obvious, also look to see if there were circumstances that “nudged” the provider to order the test. Was the test part of a “panel” or was ordering the test influenced by its appearance on a standardized order set or clinical protocol or the way the lab requisition was formatted (some commercial labs use the requisition form in a manner that tends to “market” certain tests).
Was the timing of the ordered test appropriate? For example, if the test was for a serum anticonvulsant level was the test likely ordered before a steady state level would have been achieved? Or if it is an HbA1C level has enough time elapsed since the change in management that the HbA1C level would reflect the overall glycemic status resulting from that change?
The patient interaction must be considered as well. Was the reason for the test discussed with the patient? Was special preparation for the test (eg. fasting) discussed with the patient? Most importantly, did the provider discuss with the patient how long it would be before the test results come back and how the result will be communicated with him/her (more on that on the post-analytic phase)?
Lastly, and most importantly, before ordering a test the clinician should ask him/herself, and discuss with the patient (1) what will we do if the test result is normal? (2) what will we do if it is abnormal as we expect it to be? (3) what will we do if it shows us something unexpected? For example, do you really need to order that C-reactive protein (CRP) in your patient who has multiple CAD risk factors and a high LDL who you are going to treat with statins regardless of the CRP result?
Keep in mind that some lab results may be “abnormal” by chance. If you have a 5% chance that a test result will fall outside the “normal range” statistically and you order a comprehensive metabolic profile of 18-20 tests you are very likely to have one test result that is “abnormal”. Interestingly, when we talk to lab directors we often get responses like “it is less expensive and more efficient for me to run the panel than the individual test”. That, however, fails to take into account the expense and inconveniences that will be generated following up on such an “abnormal” result.
Step 3 How was the test ordered?
Was it written out on a prescription form? Was a lab requisition used? Was CPOE used? Regardless of the method used, was the intent of the order clear? Were there handwriting issues? Inappropriate abbreviations used? Was it clear who was ordering the test? (Ever get a test report for a patient who was not your patient because the lab could not read the name of the actual ordering physician?)
Note that some errors in Steps 2 and 3 may be reduced by use of electronic laboratory utilization management systems. A recent study (Konger 2016) found that such a system effectively reduced unnecessary lab testing. Laboratory cost savings were estimated on the order of $150,000 annually for one hospital and no adverse effects on patient care were reported.
Step 4 Specimen Collection
Where, when and how was the specimen obtained? Were the appropriate patient identification procedures used prior to obtaining the specimen? Were the correct tubes or other containers used for collecting the specimen? Were they correctly labeled? Are all specimens labeled immediately and individually? How did they get to the lab (collected at the lab, sent by courier to the lab, transported from a hospital unit to the lab, etc.)? Do you have a system that actually tracks the specimen on its way to the lab? How do you know if a specimen never reached the lab? If the specimen and test were time-sensitive, did the specimen get to the lab within the appropriate time frame?
Again, see our Patient Safety Tips of the Week for October 9, 2007 “Errors in the Laboratory“ and November 16, 2010 “Lost Lab Specimens” for discussions on specimen identification, labeling, etc. Some best practices to help avoid patient misidentification and specimen labeling errors are use of barcoding, use of at least 2 patient identifiers, use of biometrics, and labeling the specimen containers immediately after specimen collection (for example, printing labels and affixing them right at the bedside when the specimen is obtained).
We also recommend you pay particular attention to sites doing point of care (POC) testing, whether in the office or at the bedside in the hospital. Our experience is that procedures for identification and labeling of specimens in those settings are more prone to “workarounds” and thus more errors.
Our March 6, 2012 Patient Safety Tip of the Week ““Lab” Error” also addressed the need to analyze your post-analytic steps. See that column and our numerous columns on communicating significant test results (listed below).
Some of our other columns on errors related to laboratory studies:
See also our other columns on communicating significant results:
ECRI Institute. From the ECRI Institute PSO Deep Dive: An Examination of “Lab” Errors. ECRI Institute PSO Monthly Brief 2014; May 2014
Green SF. The cost of poor blood specimen quality and errors in preanalytical processes. Clin Biochem 2013; 46(13): 1175-1179
Atwaru A, Duen M, Poczter H, Giugliano E. The Cost of Quality. Pathology and Lab Medicine 2016 American Society for Clinical Pathology (ASCP) Annual Meeting: Poster LP10. Presented September 14, 2016
Kaushik N, Green S. Pre-analytical errors: their impact and how to minimize them. MLO Online 2014; May 18, 2014
Martin, H., Metcalfe, S. & Whichello, R. (June 2015). Specimen labeling errors: A retrospective study. Online Journal of Nursing Informatics (OJNI), 19 (2), Available at http://www.himss.org/ojni
Koppel R, Wetterneck T, Telles JL, Karsh B-T. Workarounds to Barcode Medication Administration Systems: Their Occurrences, Causes, And Threats To Patient Safety. JAMIA 2008; 15(4): 408-423 First published online 1 July 2008
Konger RL, Ndekwe P, Jones G, et al. Reduction in Unnecessary Clinical Laboratory Testing Through Utilization Management at a US Government Veterans Affairs Hospital. Am J Clin Path 2016; 145(3): 355-364 First published online: 18 February 2016
Print “Lab Errors Costly”
To get "Patient Safety Tip of the Week " emailed to you, click here and enter "subscribe" in the subject field.
If you don't see the search term you expected to see here, its probably because that tip already went to our Tip of the Week Archive. We do a new tip every week. Click here to search the entire site or you can Go to Tip of the Week Archive a patient safety resource solution loaded with tips, tools, and techniques you can use in your patient safety and quality improvement initiatives. Or it may have moved to our What's New Archive.
Click here to see the consulting services and patient safety solutions that we provide.
Click on the "Contact Us" button at the left to send us your comments on our "What's New in the Patient Safety World" columns.
To get "Patient Safety Tip of the Week "emailed to you, click here and enter "subscribe" in the subject field.
Two recent studies done on specialized patient populations identified combinations of interventions that were able to reduce hospital-acquired infections (HAI’s) by over 50%. The first study utilized a bundle of evidence-based interventions in patients undergoing spine surgery (discectomy, decompression, spinal augmentation or spinal fusion) and found surgical site infections declined by 50% after implementation (Featherall 2016). Components of the “bundle” were:
The number needed to treat (NNT) to prevent one infection was 47 patients. In addition to the 50 percent decline in SSIs there was an $866 cost reduction per case.
The second study (Halperin 2016) involved ventilator patients in patients in neurointensive care units and found an HAI reduction of 53% over an 18 month period. The two main interventions were (1) reducing the number of intrahospital transports and (2) reducing the number of urinary catheters. The primary way intrahospital transports was reduced was by the introduction of a mobile CT scanner so that patient needing frequent brain imaging could have the imaging done in the neuro ICU rather than being transported to the CT suite. Reduction in urinary catheters was accomplished by daily assessment of the continued need for such catheters, plus staff re-education on insertion and maintenance techniques plus introducing a new Foley kit that simplified and standardized the sterile insertion process Ventilator-associated events decreased 48 %, Foley use decreased 46 %, CAUTIs decreased from 11 per 1000 catheter days to 6.2.
Given our multiple columns on adverse events occurring in the Radiology suite (see full list below but in particular see our October 22, 2013 Patient Safety Tip of the Week “How Safe Is Your Radiology Suite?”) we would be interested to see if the reduction in transports to Radiology also resulted in fewer overall adverse events of other types. That may well have been the case since they also found overall complication rate decreased 55 %, ICU length of stay decreased an average of 1.5 days, and risk-adjusted mortality decreased 11%.
Lastly, back to one of the most important interventions to reduce HAI’s: good hand hygiene. We often have difficulty convincing our healthcare workers (particularly our physicians) that better compliance with hand hygiene actually translates to fewer HAI’s. That is especially a problem where levels of compliance with hand hygiene are already relatively high. Well, a recent study in CDC’s Emerging Infectious Diseases journal should bolster your argument. Researchers from UNC Chapel Hill (Sickbert-Bennett 2016) found that taking a hand hygiene compliance rate of >80% to an even higher one at >95% resulted in a further significant reduction in HAI’s. The association between hand hygiene compliance and HAI showed a 10% improvement in hand hygiene was associated with a 6% reduction in overall HAI rate. The association between hand hygiene compliance and HA-CDI (healthcare associated C. diff infection) showed a 10% improvement in hand hygiene was associated with a 14% reduction in HA-CDI. No association was noted between hand hygiene compliance and MDRO infections. While the authors could not rule out a contribution from unknown confounders, there were no other specific infection prevention goals adopted during the study period.
Read the Sickbert-Bennett article for details on their successful interventions. But key features were that the focus for observation was simply on cleaning hands upon entering and leaving patient rooms and that all healthcare personnel (including physicians, advanced practice providers, nurses, nursing assistants, hospital unit coordinators, housekeeping, radiology, occupational/physical/recreational therapists, nutrition and food services staff, phlebotomists, and respiratory therapists) were asked to make observations and provide immediate feedback to each other.
Some of our prior columns on patient safety issues in the radiology suite:
Our other columns on urinary catheter-associated UTI’s:
Some of our other columns on handwashing and hand hygiene:
January 5, 2010 “How’s Your Hand Hygiene?”
December 28, 2010 “HAI’s: Looking In All The Wrong Places”
May 24, 2011 “Hand Hygiene Resources”
October 2011 “Another Unintended Consequence of Hand Hygiene Device?”
March 2012 “Smile…You’re on Candid Camera”
August 2012 “Anesthesiology and Surgical Infections”
October 2013 “HAI’s: Costs, WHO Hand Hygiene, etc.”
November 18, 2014 “Handwashing Fades at End of Shift, ?Smartwatch to the Rescue”
January 20, 2015 “He Didn’t Wash His Hands After What!”
September 2015 “APIC’s New Guide to Hand Hygiene Programs”
November 2015 “Hand Hygiene: Paradoxical Solution?”
April 2016 “Nudge: An Example for Hand Hygiene”
August 2016 “Hand Hygiene: Who’s Watching? Does it Matter?”
Featherall J, Miller JA, Bennett EE, et al. Implementation of an Infection Prevention Bundle to Reduce Surgical Site Infections and Cost Following Spine Surgery. JAMA Surgery 2016; Online First July 20, 2016
Halperin JJ, Moran S, Prasek D, et al. Reducing Hospital-Acquired Infections Among the Neurologically Critically Ill. Neurocritical Care 2016; 1-8 First online: 27 June 2016
Sickbert-Bennett EE, DiBiase LM, Schade Willis TM, et al. Reduction of Healthcare-Associated Infections by Exceeding High Compliance with Hand Hygiene Practices. Emerging Infectious Diseases 2016; 22(9): September 2016
We all assume that ICU’s are good things and that you’ll receive better and safer care in an ICU almost regardless of what your medical problem is. But a new study challenges that assumption. Researchers from the University of Michigan (Valley 2016) analyzed data from Medicare’s Hospital Compare database and found that hospitals with high ICU use for patients with acute MI or CHF exacerbation often had higher mortality rates and lower rates of using evidence-based testing and treatments. For example, MI patients in high ICU use hospitals were less likely to receive aspirin on arrival. MI patients treated in high-ICU hospitals were 6 percent more likely to die within 30 days than patients admitted to low-ICU hospitals, and the difference was about 8 percent for heart failure patients. Hospitals treating smaller numbers of MI and CHF patients and for-profit hospitals tended to have higher use of ICU beds. Patients from lower income zip codes also tend to be overrepresented in the high-ICU hospitals.
Some of the same researchers last year identified similar findings in patients with pneumonia (Sjoding 2015). Hospitals with the highest rates of ICU admission for Medicare patients with pneumonia were less likely to deliver pneumonia processes of care (such as appropriate initial antibiotics and pneumococcal vaccination) and had worse outcomes (higher 30-day mortality and higher readmission rates) for Medicare patients with pneumonia. Hospital spending for pneumonia patients was also higher in high-ICU hospitals.
Somewhat difficult to reconcile with the latter study was another one by many of the same researchers (Valley 2015). They found in Medicare patients with pneumonia that patients with “discretionary” admission to ICU’s had a significantly lower adjusted 30-day mortality. That means that patients who were “borderline” for ICU admission actually had a mortality benefit over those with similar features who were admitted to general wards. That was the opposite of what the researchers expected to find. It is not really clear why these findings differed from those in the Sjoding 2015 study.
Another new study looked at the associations between hospital-level ICU utilization rates and risk-adjusted hospital mortality, use of invasive procedures, and hospital costs (Chang 2016). For each of the 4 medical conditions studied (DKA, PE, UGIB, and CHF) hospital-level ICU utilization rate was not associated with hospital mortality. But use of invasive procedures and costs of hospitalization were greater in institutions with higher ICU utilization for all 4 conditions. They also found that hospitals had similar ICU utilization patterns across the 4 medical conditions studied, suggesting that systematic institutional factors may influence decisions to potentially overutilize ICU care.
Fortunately, in a timely release, the Society for Critical Care Medicine has just updated its guidelines for admission to and discharge from critical care units (Nates 2016). The guidelines also have recommendations for prioritization and triage of potential ICU patients based upon factors such as severity of illness, functional impairment, comorbidities, prognosis for recovery and quality of life, patient preferences with regard to life-sustaining treatment, etc. Chronological age should not be a primary determinant in the elderly. One important recommendation under discharge guidelines is to avoid “after hours” discharge (see our December 9, 2008 Patient Safety Tip of the Week “Huddles in Healthcare” regarding huddles with bed coordinators to avoid such after hours transfers from the ICU). The guidelines also discuss potential sites to which discharge from the ICU can occur, including general wards, step down units, post-acute care facilities, etc. They also discuss use of outreach programs to supplement ICU care, such as rapid response teams and ICU consult teams on wards.
Hospitals need to take a close look at their ICU utilization. We still see hospitals that lack formal criteria for ICU admission and discharge or have them but don’t adhere to them. Yes, ICU’s provide patients with levels of nursing care and monitoring that should be advantageous but they also expose patients to a variety of potential hazards (nosocomial infections, invasive procedures, etc.). And provision of services that don’t result in better patient outcomes may be detrimental to the fiscal health of the hospital.
Valley TS, Sjoding MW, Goldberger ZD, Cooke CR. Intensive care use and quality of care for patients with myocardial infarction and heart failure. Chest 2016; In Press Accepted Manuscript, Available online 15 June 2016
Sjoding MW, Prescott HC, Wunsch H, Iwashyna TJ, Cooke CR. Hospitals with the highest intensive care utilization provide lower quality pneumonia care to the elderly. Crit Care Med 2015; 43(6): 1178-1186
Valley TS, Sjoding MW, Ryan AM, Iwashyna TJ, Cooke CR. Association of Intensive Care Unit Admission With Mortality Among Older Patients With Pneumonia. JAMA 2015; 314(12): 1272-1279
Chang DW, Shapiro MF. Association Between Intensive Care Unit Utilization During Hospitalization and Costs, Use of Invasive Procedures, and Mortality. JAMA Intern Med 2016; Published online August 08, 2016
Nates JL, Nunnally M, Kleinpell R, et al. ICU Admission, Discharge, and Triage Guidelines. A Framework to Enhance Clinical Operations, Development of Institutional Policies, and Further Research. Crit Care Med 2016; 44(8): 1553-1602
Tired of seeing your surgeons and OR personnel traipsing through your hospital cafeteria dressed in their scrubs (with all the contaminants you don’t want to even think about)? Well, get them all to comply with the new recommendations in a statement from the American College of Surgeons (ACS) on operating room attire (ACS 2016). And, while you are at it, make sure everyone in your cath labs or GI labs or other procedure areas also comply with the new recommendations.
The ACS bases its guidelines for appropriate attire on “professionalism, common sense, decorum, and the available evidence”. They are as follows:
The ACS strongly suggests that scrubs should not be worn outside the perimeter of the hospital by any health care provider. To facilitate enforcement of this guideline for OR personnel, the ACS suggests the adoption of distinctive, colored scrub suits for the operating room personnel.
But not everyone is on board with the ACS statement. In particular, AORN (Association of periOperative Registered Nurses) has issued its own statement (AORN 2016) noting that several of the ACS recommendations are not evidence-based. The AORN statement comments on the ACS recommendations item-by-item but especially differs on several points. Whereas the ACS statement recommends that “Scrubs and hats worn during dirty or contaminated cases should be changed prior to subsequent cases even if not visibly soiled.” AORN notes that OSHA requires "attire that has been penetrated by blood, body fluids, or other infectious materials be removed immediately or as soon as possible and be replaced with clean attire." AORN also questions the recommendation about wearing a lab coat over scrubs, noting evidence that lab coats are often contaminated by large numbers of pathogenic organisms. AORN also discusses issues regarding head coverings and how difficult it would be for facilities to enforce vague terminology like “modest sideburn” or “limited amount of hair”. Read the AORN statement in full for other details. AORN also has its own guidelines on surgical attire.
The ACS plans to publish its statement in the October 2016 issue of Bulletin of the American College of Surgeons. One would hope that ACS and AORN would get together with the ASA (American Society of Anesthesiologists) and organizations representing all other OR healthcare workers to agree on standards that apply to all.
ACS (American College of Surgeons). Statement on Operating Room Attire. Online August 4, 2016
AORN (Association of periOperative Registered Nurses). AORN Responds to ACS Statement on Surgical Attire. Periop Insider Newsletter 2016; August 16, 2016
AORN (Association of periOperative Registered Nurses). Clinical FAQ’s. Surgical Attire.
A recent report by the Office of the Inspector General (Levinson 2016) found that 29% of Medicare patients admitted to a post-acute rehabilitation facility (rehab units in acute care hospitals were excluded) experienced either an adverse event or temporary harm event. Almost half (46%) of these were deemed to be likely preventable. About a quarter of the events led to acute care hospitalizations, which were estimated to cost Medicare $92 million annually.
The results were based upon a sample of 417 Medicare patients discharged from such units in March 2012. This event rate is really quite similar to rates the OIG has found for Medicare patients in acute hospitals (27%) and SNF’s (33%). 10% of the patients had an adverse event, which implied harm came to the patient. An additional 18% had events that led to temporary harm. 1.7% of patients had “cascade” events (where multiple related adverse events or temporary harm events occurred in succession). But only 0.7% had events that caused or contributed to their death.
We don’t think the OIG’s report is meant to single out rehab facilities. Rather, it simply demonstrates that all the factors which contribute to adverse events in hospitals are not unique to general hospitals but also occur in almost all healthcare settings.
Levinson DR (Office of the Inspector General. Adverse Events in Rehabilitation Hospitals: National Incidence Among Medicare Beneficiaries. July 2016
Go to the "Whats New Archive"
To get "What's New in the Patient Safety World"emailed to you,click here and enter "subscribe" in the subject field.
To get "What's New in the Patient Safety World"emailed to you,click here and enter "subscribe" in the subject field.