RL Solutions patient safety reports lead to changes in the Laboratory

At Brigham and Women’s Faulkner Hospital, patient safety is always a top priority and it’s an area in which we can always improve. That’s why “Highest Quality, Safest Care” has been identified by hospital leadership as a key goal for 2018. Recent changes made in the Laboratory highlight just how impactful it can be when staff report patient safety issues in RL Solutions, BWFH’s patient safety reporting system, in terms of driving change and improving outcomes for our patients.

“We noticed quite a few reports in RL Solutions related to early morning blood draws,” says Executive Director of Patient Safety, Quality, Risk, Infection Control, CDI and Clinical Compliance Christi Clark Barney, MSN, RN. “Some of it was related to how the order flows from Epic to the hand-held devices the phlebotomists use. Using the Just Culture algorithm, we identified these as system issues. But we also identified another system issue. It turns out, a portion of the phlebotomy staff wasn’t scheduled to start their day until 7 am while the clinical staff was under the impression patients should have their blood draws at 6:30 am.”

After examining the various reports, the Laboratory implemented several simple changes in Phlebotomy that have shown to be very effective:

• A department coordinator was added to triage issues between the front desk and technical lab
• More phlebotomists were hired and the phlebotomist start time has been adjusted to 6 am
• Phlebotomists now carry Vocera, a device that allows for direct communication with the nurses on the unit

“Adding more staff and having them come in earlier has allowed for optimal coverage,” says Laboratory Director Rachel Ambacher, MS, MT(HEW). “It’s also improved STAT (emergency tests) and timed collections as there are more phlebotomists available on all shifts to collect specimens.”

Having the phlebotomists carry a Vocera has also improved communication and therefore efficiency. “The clinical staff can now communicate with the Phlebotomy team immediately,” Ambacher explains. “That means there’s a decrease in the response time for patients with an immediate collection need.”

For Barney, the work done in the Laboratory proves just how much input frontline staff can have in invoking change when they report issues to RL Solutions. “The Lab does a huge volume of tests. We found out that it’s only one test in about 9,000 where there is an actual error in the result, but by using the Just Culture algorithm they were able to respond to the system issues that were discovered. It goes to show, safety reporting does translate into changes in the way we do things. Having specific events reported allowed us to investigate and clarify the real issues.”