Teaching from the test

Here is a recent entry from the SPIRIT call-out log, as an example of the types of things that are found and the process for fixing them. Sometimes existing sources of information are not effectively used because of a lack of knowledge or training about them. As always, the key here is not to blame anyone. It is to solve the problem called out and then to promulgate the solution throughout the organization.

PROBLEM: The lab test entered in the lab (Metanephrines) was different than the lab ordered on order requisition (Methemoglobin).

ROOT CAUSE: Why was Metanephrines entered into lab system instead of Methemoglobin? Metaneprines was selected from the list of 9 choices displayed in the blood lab information system when lab assistant typed in "MET". Assistant selected metanephrines (plasma) because asked a coworker what to select was told to pick this one because purple top vial is associated with plasma. Methemoglobin was not an option to select. Why was methemoglobin not an option to select? Assistant was working in blood lab information system. Methemoglobin is a blood gas test and is an option in that system only. Why was the assistant working within the blood lab information system? The requisition that the EP lab sent to the lab was a blood lab requisition not a blood gas requisition. Why did the EP lab send a blood lab requisition? The person requesting the lab test was unfamiliar with the test and did not have the information necessary regarding the type of tube and requisition to use. (Asked 4 people in cath department and lab and received inaccurate information and sent purple top and blood lab req. )

SOLUTION: Design a way for workers to have accurate information regarding which blood tube and requisition to use for each test. (Access to electronic URL that contains the lab resource manual on BIDMC website.)

ACTION: Wayne (Lab department manager) demonstrated the online lab reference to the nurses in the EP lab. Will continue to work with lab and nurses to work on a way for them to have the information that they need when requesting lab tests. Wayne will also work with his staff regarding a way to call out for help when the exact lab test requested is not an option to enter into the system.

Notes: The problem was found serendipitously when looking at a lab requisition for another issue (a half-printed patient plate). Wayne learned as much as he could from his staff then activated the help chain to request help in further investigation in the EP lab. Nurses in EP lab and in our small group were unaware of the online resource available to them and grateful to learn about it. This surprised Wayne. Question for consideration: Are the other nurses in the organization aware of this extremely useful tool and if not how can this be communicated to them?