Patient Safety Issues. Where Does the Lab Professional Fit In?. Mary Ann McLane, PhD, CLS(NCA) Region II Director. The patient must come first!. Objectives. At the conclusion of this seminar, the participant will be able to:
Where Does the Lab Professional Fit In?
Mary Ann McLane, PhD, CLS(NCA)
Region II Director
At the conclusion of this seminar, the participant will be able to:
You can try to swat them one at a time, but there will always be others to take their place. The only effective remedy is to drain the swamps in which they breed. In the case of errors and violations, the "swamps" are equipment designs that promote operator error, bad communications, high workloads, budgetary and commercial pressures…
…procedures that necessitate their violation in order to get the job done, inadequate organization, missing barriers, and safeguards . . . the list is potentially long but all of these latent factors are, in theory, detectable and correctable before a mishap occurs.
To Err Is Human
Discussion point: expected of an “average physician” only?
1. How frequently do errors occur?
2. What factors contribute to errors?
3. What are the costs of errors?
4. Are public perceptions of safety in health care consistent with the evidence?
physician chooses an appropriate medication, writes 10 mg when the intention was to write 1 mgaaaaaaaaaaaaaaaaaaaaaaaaaaaa
• Have a pharmacist available on nursing units and on rounds.
(why just a pharmacist? Commercial minute for the professional DLM doctorate…)
• Use computerized lab data that alert clinicians to abnormal lab values.
• Place lab reports and medication records at the patient's bedside.
• Place protocols in the patient's chart.
• Color-code wristbands to alert of allergies.
• Track errors and near misses and report them regularly.
• Accelerate laboratory turn around time.
…also noted the importance of involving the patient in their own care…commercial about the ASCLS consumer webpage
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630-792-5800, option 5
Computerized prescribing Organizations
Including pharmacists on rounds
Standardizing medication practices
Preventable adverse events down 78%
Adverse events down 60%2005 JAMA (Lucian Leape, Donald Berwick)