Guest Commentary by: Mark Graban
Clinical laboratory professionals and leaders should be reminded that their accountability for quality and patient safety does not end at the instrument or the microscope—at least from the general public’s perception and the needs of patients.
This summer, I was walking through Boston Common and saw a woman with a homemade sign with a message about patient safety. I stopped and asked about her sign. She reminded me it was July 25, the annual observance of National Patient Safety Day.
As we chatted, I learned that this woman’s father had died, arguably, due to a laboratory error, as she described it. One of his lab tests came back in the critical range, but he didn’t get the correct medical response in a timely manner. She categorized the episode as a “lab error” although it was not an incorrect test result.
According to her, her father’s lab test report with the critical result sat and went unobserved by either staff or physician. It went unobserved by either staff or physician. Her father’s condition worsened during the time the report went unread. She ended up calling 911, but he soon passed away. By her telling of the story, it sounded like an issue that would not have been fatal if the critical test result had been brought to the attention of the attending physician in a timely manner.
She and I chatted further. We were in quick agreement that this was an avoidable process error. The error was in what we might call, in the Lean vernacular, the “laboratory testing value stream”—part of the entire end-to-end process. This was a case where the value stream wasn’t well designed—or it wasn’t well executed by any of the parties involved in ordering the lab test, reporting the results, and acting upon the information deemed “critical” by the laboratory.
This brings me to the main point of this commentary. Who was responsible for this error that my new-found friend believes contributed to the avoidable death of her father? Certainly the laboratory plays an important role as it diligently follows its established processes for reporting critical values.
But, in the value stream—and under the philosophy of System of Prevention—whose role is it to ensure the communication (the lab test report with a critical result) is received, not just sent? Laboratory leaders are placed in a tough situation because no single entity or individual is responsible for the entire process from start (the test order being placed) to finish (when the ordering physician makes a treatment decision based on the test result).
I recommend that laboratory and hospital leaders take the lead in introducing better processes or new technologies that are less prone to human error, as occurred in this situation. It is not enough to say, “that wasn’t our lab’s responsibility. It was the doctor’s fault.” Your clinical laboratory might have hundreds of ordering physicians—so it makes sense for your laboratory to take the lead on necessary process improvements, even when it involves the referring physicians’ office as part of the total value stream. That likely means proactively asking referring physicians and their staff to collaborate in sessions to review the entire value stream, identify causes of errors and failure, and then make improvements in the value stream that correct those issues.
The woman I met that day in Boston Commons, like many other family members or loved ones of medical error victims, has thankfully channeled her energy into education and prevention, not anger and revenge. She runs a Web site called www.voice4patients.com. I invite you to visit her Web site and share your thoughts on the laboratory’s role in patient safety.
She and I agreed that patient safety should be a top priority every day, not just July 25. We were also in agreement that the path to improvement is NOT one of blame and punishment after something goes wrong. The best path to improvement involves proactive prevention, awareness, and adherence to standardized processes that could prevent tragedies like her father’s.
Today’s guest commentator, Mark Graban, is a Senior Fellow with the not-for-profit Lean Enterprise Institute in Cambridge, Massachusetts. He helps run the Healthcare Value Leaders Network. In his prior role with ValuMetrix Services at Ortho-Clinical Diagnostics, he led Lean transformations in four hospitals in the United States and England and educated thousands of laboratory professionals in Lean practices.
He is author of the book “Lean Hospitals: Improving Quality, Patient Safety, and Employee Satisfaction” and runs the Lean Blog. Graban has also presented at the Executive War College and the Lab Quality Confab .
Related Information:
World Patient Safety Day Web site
Becky Martins is a passionate, tireless and active patient safety advocate. She is not into self promotion, rather using her father’s terrible experience and his memory to help to cause constructive change in patient safety.
very impressive