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Eliminating Specimen Labeling Errors in Post Anesthesia Care Unit (PACU)
ASPAN NATIONAL CONFERENCE ABSTRACTS (IT) and the Department of Anesthesiology, revising the Discharge by Criteria Stage I Policy and PACU guidelines to reflect current evidence-based practice, creating partnerships with inpatient units to improve transfer times, and collaborating with management to improve staffing. Significance of Findings/Outcomes: The average PACU length of stay per patient decreased from 104 minutes in 2014 to 100 minutes in 2015. A total of 9,947 patients in 2015 (22% increase from 2014), and a reduction of 4 minutes per patient saved 39,788 minutes and an estimated $459,551 in hospital cost in 2015. Implications for perianesthesia nurses and future research: To decrease length of stay, post anesthesia care units need to adhere to evidence-based standards and guidelines developed by professional organizations. Interprofessional collaboration is integral to developing best practice.
ELIMINATING SPECIMEN LABELING ERRORS IN POST ANESTHESIA CARE UNIT (PACU) Primary Investigator: Lini Thomas, RN MSN CCRN Cedars-Sinai Medical Center, Los Angeles, California Co-Investigators: Joey Yap, BSN RN CPAN, Shirley Sabarre, BSN RN, Dawn Sullivan, BSN RN CCRN
Introduction: Inaccurately identified specimens can result in critical patient safety issues through delayed or wrong diagnoses, missed or incorrect treatments, blood transfusion errors, and the need for additional laboratory testing. Identification of the problem: In a study conducted at our organization, all clinical areas achieved a significant decrease in mislabeled specimens except perioperative areas and labor and delivery which was attributed to multiple pathways in test ordering and lack of process uniformity in specimen labeling (Seferian et.al, 2014). A root cause analysis (RCA) done on five labeling errors in PACU for the fiscal year 2015 showed all cases used a downtime form with wrong patient labels. Purpose of the Study: The purpose of the study was to understand if the implementation of a standardized process reduces or eliminates specimen labeling errors in PACU. Methodology: PDSA (Plan, Do, Study, Act). A simplified visual guide “STOP & CHECK” was formulated. A standardized method was encouraged using the electronic label printer and discouraged the use of downtime forms. The nurses were instructed to perform a final check at the bedside, verbalizing two identifiers (name & medical record number) with a second nurse before sending the specimen to the lab. The project was piloted in two PACUs where mislabeling events happened. One on one education was given to all the nurses and compliance monitored through direct observation. The specimen labeling errors were tracked from the launch of the project in April 2015 to February 2017.
Note: All abstracts are printed as received from the authors.
e53
Results: One specimen error occurred in August 2015 after the launch of the project. An RCA confirmed deviation in the process when the nurse used a downtime form as the lab label printer was not readily available in the pre-op area. A dedicated lab label printer was installed in the area, and no mislabeling event has occurred since then. The mislabeling events for PACU has remained zero for 18 months. Discussion: Standardization of specimen collection process reduces confusion among nurses during specimen collection. Conclusion: Zero specimen labeling errors occurred with the use of the standardized process. An annual competency for staff will be conducted and the standardized procedure will be reinforced by the authors. Implications for perianesthesia nurses and future research: The success of the project has encouraged the authors to standardize the specimen labeling process in other PACUs. The project has been disseminated to other PACUs with the aid of unit practice council.
PATIENT LIAISON - BRIDGING THE GAP OF COMMUNICATION TO PATIENTS AND FAMILIES Primary Investigator: Tesha Seabra, BSN RN CPAN Cedars Sinai Medical Center, Los Angeles, California Co-Investigators: Bridgitte DeJesus, MSN RN CPAN, Alena Mascetta, BSN RN CPAN CCRN, Sol Briones, BSN RN CPAN Identification of the problem e Overview: Consistency is critical in facilitating the admission process to the operating room (OR). In the Post Anesthesia Care Unit (PACU) we capture monthly data in relation to preoperative room delays and patient notification of these delays. Our target goal has been 90% or higher for patient notification of surgery delays. For fiscal year 2014 our score has remained on average 84% related to the inability of the preoperative staff being available to communicate with patients and families. Communication also affects our patient satisfaction scores. Complaints have been addressed monthly related to patient and families’ inability to get information in the waiting areas, having the lobby area unattended between the hours of 0600-0900, and lack of posted contact information. EP Question/Purpose: Will having a patient liaison in the lobby area help improve on timely surgery starts, decrease cost, facilitate the admission process, improve our patient/family notification of delay and increase our patient satisfaction scores? Methods/Evidence: PDSA (Plan, Do, Study, Act). With Unit Practice Council (UPC) approval, a patient liaison was trained to be in the lobby area starting at 6a. This is the time that patients arrive in the preoperative waiting area for surgery. The patient liaison will have access to the surgical schedule and collaborate with the OR/Preop/PACU to improve efficiency by updating patients and families along with bridging the gap of communication in relation to preoperative delays and updating families of patient’s status. We will analyze the data by recording how many patient and family interactions the liaison encountered. We will also perform post-operative rounding on the patients to ask if questions and concerns were addressed on admission. We will continue our monthly performance measures and determine if the percentage of
ELIMINATING SPECIMEN LABELING ERRORS IN POST ANESTHESIA CARE UNIT (PACU) Primary Investigator: Lini Thomas, RN MSN CCRN Cedars-Sinai Medical Center, Los Angeles, California Co-Investigators: Joey Yap, BSN RN CPAN, Shirley Sabarre, BSN RN, Dawn Sullivan, BSN RN CCRN
Introduction: Inaccurately identified specimens can result in critical patient safety issues through delayed or wrong diagnoses, missed or incorrect treatments, blood transfusion errors, and the need for additional laboratory testing. Identification of the problem: In a study conducted at our organization, all clinical areas achieved a significant decrease in mislabeled specimens except perioperative areas and labor and delivery which was attributed to multiple pathways in test ordering and lack of process uniformity in specimen labeling (Seferian et.al, 2014). A root cause analysis (RCA) done on five labeling errors in PACU for the fiscal year 2015 showed all cases used a downtime form with wrong patient labels. Purpose of the Study: The purpose of the study was to understand if the implementation of a standardized process reduces or eliminates specimen labeling errors in PACU. Methodology: PDSA (Plan, Do, Study, Act). A simplified visual guide “STOP & CHECK” was formulated. A standardized method was encouraged using the electronic label printer and discouraged the use of downtime forms. The nurses were instructed to perform a final check at the bedside, verbalizing two identifiers (name & medical record number) with a second nurse before sending the specimen to the lab. The project was piloted in two PACUs where mislabeling events happened. One on one education was given to all the nurses and compliance monitored through direct observation. The specimen labeling errors were tracked from the launch of the project in April 2015 to February 2017.
Note: All abstracts are printed as received from the authors.
e53
Results: One specimen error occurred in August 2015 after the launch of the project. An RCA confirmed deviation in the process when the nurse used a downtime form as the lab label printer was not readily available in the pre-op area. A dedicated lab label printer was installed in the area, and no mislabeling event has occurred since then. The mislabeling events for PACU has remained zero for 18 months. Discussion: Standardization of specimen collection process reduces confusion among nurses during specimen collection. Conclusion: Zero specimen labeling errors occurred with the use of the standardized process. An annual competency for staff will be conducted and the standardized procedure will be reinforced by the authors. Implications for perianesthesia nurses and future research: The success of the project has encouraged the authors to standardize the specimen labeling process in other PACUs. The project has been disseminated to other PACUs with the aid of unit practice council.
PATIENT LIAISON - BRIDGING THE GAP OF COMMUNICATION TO PATIENTS AND FAMILIES Primary Investigator: Tesha Seabra, BSN RN CPAN Cedars Sinai Medical Center, Los Angeles, California Co-Investigators: Bridgitte DeJesus, MSN RN CPAN, Alena Mascetta, BSN RN CPAN CCRN, Sol Briones, BSN RN CPAN Identification of the problem e Overview: Consistency is critical in facilitating the admission process to the operating room (OR). In the Post Anesthesia Care Unit (PACU) we capture monthly data in relation to preoperative room delays and patient notification of these delays. Our target goal has been 90% or higher for patient notification of surgery delays. For fiscal year 2014 our score has remained on average 84% related to the inability of the preoperative staff being available to communicate with patients and families. Communication also affects our patient satisfaction scores. Complaints have been addressed monthly related to patient and families’ inability to get information in the waiting areas, having the lobby area unattended between the hours of 0600-0900, and lack of posted contact information. EP Question/Purpose: Will having a patient liaison in the lobby area help improve on timely surgery starts, decrease cost, facilitate the admission process, improve our patient/family notification of delay and increase our patient satisfaction scores? Methods/Evidence: PDSA (Plan, Do, Study, Act). With Unit Practice Council (UPC) approval, a patient liaison was trained to be in the lobby area starting at 6a. This is the time that patients arrive in the preoperative waiting area for surgery. The patient liaison will have access to the surgical schedule and collaborate with the OR/Preop/PACU to improve efficiency by updating patients and families along with bridging the gap of communication in relation to preoperative delays and updating families of patient’s status. We will analyze the data by recording how many patient and family interactions the liaison encountered. We will also perform post-operative rounding on the patients to ask if questions and concerns were addressed on admission. We will continue our monthly performance measures and determine if the percentage of