Transcription errors can maim and kill

I have said on a number of occasions that we run a microbiology proficiency testing program that is predicated on the use of simulation as a learning and challenging process.  If our samples look and act like real samples, then laboratories can use them in a variety of ways to improve process.  A recent survey indicates that we get a lot of support from our participants because of our simulation potential (more on this later).  

But there is one situation in which we do not get a lot of support; indeed some folks get really angry.  We have a committee philosophy and policy that says that our samples have identification with two identifiers and we consider that as the sample’s name.  If a sample is not designated by its proper name, regardless of the work performed, the sample fails.   This genuinely upsets some of the laboratories because they see this as unfair and unreasonable.  

With respect, I disagree.  We refer to improper naming of samples or indeed any incorrect submission of  forms as a post-examination error.  And we take a very aggressive attitude towards post-examination error.

Jump to yesterday’s National Post, one of Canada’s most prestigious national newspapers.  With disappointment we read the story of 4 women who were severely harmed and indeed maimed by the healthcare industry because someone put the wrong breast biopsy report on the wrong patient’s chart, resulting in the wrong person getting the wrong surgery.  In another mix-up the wrong patient ended up with a diagnostic biopsy and the other patient received delayed care because two samples that came to the laboratory got mixed up in accessioning.

One politician’s response, “We are sooo sorry“, and another was “Well, healthcare is run by people and sometimes people make mistakes”.  Another response, “Well, we were planning to put in a bar-code system that will reduce the chance of this happening again”.

Look, I have read James Reason and his books on risk and error, and I get it, sometimes people screw up;  sometimes we call them slips, sometimes we can them distractions, and sometimes we call them mistakes.  Most of the time, they are invisible or they cause at most some inconvenience.  But sometimes they don’t.  Sometime, especially in healthcare, they can hurt people.  In some industries fail-safe check systems are introduced to prevent them from happening at critical times.  In some industries they talk about fail-safe, and in others they don’t even bother talking about them.  

In the past I have talked about the casualness that exists in healthcare when it comes to post-examination error, in particular when it affects confidentiality.  [see: http://www.medicallaboratoryquality.com/2013/08/confidentiality-and-laboratory-error.html ]  If we just accept slips to occur without acknowledging their consequences, then we allow folks to not worry about them.  And that can lead to really bad outcomes.

And at that point, the problem is no longer slips and inattention, it is failure to develop policies and processes to protect patients.

So CMPT will continue to consider transcription errors as part of the proficiency testing exercise and will continue to view them as Major Errors.  

And so should you.

PS:

Our POLQM Quality Conference is coming along really well.  Hope to see you in Vancouver.  If you come, let me know that you are a sometimes reader of MMLQR.

http://polqm.ca/conference_2013/conference_2013/conference_home.html

Confidentiality and Laboratory Error

Reporting information to the WRONG person is an error that really annoys me.  Over my working years I have been involved in more than 60,000 wrong communications situations.  I see every one of these as a potential confidentiality breach.  To me it is a BIG DEAL,

I accept that Errors happen, and that many, indeed most are slips or simple mistakes, and that the preponderance of these slips are of little consequence.  Slips and simple mistakes are to a large extent, human foibles that cannot be eliminated but can be reduced, especially by having an active quality management system that includes elements of audit and risk assessment.  

I also acknowledge that I may be overly sensitive but being a recipient of errant reports puts me in the middle of a patient confidentiality breach which is beyond my control, and at the same time, puts a huge onus on me to fix someone else’s mistake.  It costs me time, effort, energy and money.  

Misdirected information,  in my opinion cannot be included within  the classification of slips and mistakes because the intrusion into confidentiality raises the consequences significantly.

Personally I thought I that I had finally solved my long-term problem because I I previously informed all key offices and organizations that I would not take any responsibility for misdirected information, and then changed my address when my programs were moved to a new location.  But I was wrong.  

I have three stories from the last little while, that stand out from the all the others.  They indicate how pervasive casualness of patient information has become in our culture.

First story.   I received a letter from a lawyer’s office requesting information on a patient.  This is not an unusual request, but became complicated because I was aware of the patient in question; not because I had a professional relationship with the person, but a social one.  I contacted the lawyer’s office by telephone giving them my name, their file number, the date of the letter and explained that they had unfortunately sent their letter to the wrong person.  I chose to not mention the additional complication of compromised identification.   What transpired was that the lawyer’s office somehow saw this was my fault and that I had an obligation to inform them in writing and return the misdirected letter back to their office.  Being polite was a bit of a challenge, but for some reason, I actually complied.  Stunningly, six weeks later, I got a “letter of second notice” from the same lawyer demanding my file information on the same patient.       

Second story.  I recently was in the hospital and was referred to a clinic for follow-up.   The day following discharge I received a telephone call from the clinic to set up my appointment.  Having set an agreed upon time, I said, that was great.  Please send me an email confirmation, to which I was informed that they do not send emails confirmations because of concerns about confidentiality breaks.  Good for them; clearly they have thought their way through some of the confidentiality issues.  OK, just send me a notice to my home address, which they could do.  The problem was that they had a wrong address.  Not only was it a wrong address, it was one that my wife recognized because it was the home address of a friend with whom I share a common first name with her husband.  “I think you are talking to the wrong Michael” I said.  “Which Michael do you think you are talking to?”  I inquired, and confirmed the mixup.  Unbeknownst to me, the husband had a similar problem and was referred to the same clinic.  Someone entering the data had integrated our two files.

Third story.  In today’s mail I received a letter from an insurance company marked “Personal and Confidential” send to my address, but not intended for me.    

So here is my point.  Where I live, attention and focus on confidentiality seems to get lip service at best.  Confidentiality breaches happen all the time and they never go away, and they are pervasive through all parts of our collective society.

I can account for some (many or even most) as the result of slips and distractions.  I suspect that many result from overworked people putting out volumes and volumes of communications.  

When some organizations try to fix the problem (like prohibiting email confirmations) often their solutions fai.  They don’t solve the problems; if anything they make situations worse.  

The tragedy is that misdirected information can be avoided with even really simple quality improvement solutions, like double checking before sending out confidential material and when there is a breach, receiving and recording notification of error and implementing remedial action.   If you can prevent and fix them all, then at least you can fix some today, and aim to prevent some others  tomorrow.

But the first step, it seems to me, is to first, to give a damn.

PS:

As an addendum, out Quality Conference is attracting attention from Canada, the US, the middle East and India.  We are pleased with the rate of registrations.  Those thinking about attending should consider registering soon. 

For more information, please visit:  http://polqm.ca/conference_2013/conference_2013/conference_home.html

Direct to Patient Reporting

On September 29, 2010 I wrote about a possible future solution to pre-examination phase error.  Today I am interested at the other end, all the problems associated with post-examination problems.  There are so many ways in which laboratories can and do mess up reporting.

We put out late reports, we lose reports, we send them out with the wrong patient name or wrong identifiers, we send the report to the right doctor with the write patient name on-time, but with the wrong information.  And we send out the right information on the right patient but to the wrong physician.  And we do it with incredible repetition and frequency.  It is disturbing how often an amended or corrected report has to go out. 

And the aforementioned doesn’t include how many confusing or ambiguous reports we send out because of our incorporated jargon and stultifying formats. 

Put them all together and the number of post-examination errors can usually run around 1-3 per thousand reports, assuming that we capture them all.  What is really scary is that in many situations, our saving grace is that most results are “normal” so that if we confuse one person’s “normal” result with another person’s normal result, we would never pick it up. 

But I saw an interesting development in an broadsheet that I get mailed to my home called “Canadian Healthcare Technology” – September 2010 (http://www.canhealth.com/).  They promote themselves as Canada’s magazine for managers and users of information systems in healthcare.  This edition has an interesting series of articles on Lean in healthcare.

More interesting, and more relevant to the topic of post-examination challenges is an article on page 8 about a system which allows patients to access their own laboratory results electronically and directly without going through a clinician or physician. 

Just reading the title made my quality antennae go up.  On the one hand I am kind of a “power-to-the-people” type guy and so the concept is pretty intriguing.  It goes to the question, whose urine is it anyways?  Who says we always need a doctor to read what is on the piece of paper, or the computer screen.

But on the other hand I am a clinician, physician, laboratorian, qualitologist, and my immediate second reaction was OMG!  Considering all the challenges we have with post-examination error at the best of time, and now we add on going direct to patient without an interpretive intermediary. And when the wrong person gets the wrong information on the wrong patient, we call that a breach of confidentiality.

It reminded me of another concept called Quality Partners, the groups with whom we routinely interact to ensure we get our quality right: standards development bodies, accreditation bodies, proficiency testing bodies, educators, professional organizations, equipment and reagents suppliers, and the Public.  We can probably continue to get along sending difficult to interpret results to the usually right and sometimes wrong physician, usually on-time, and sometimes not.  But I imagine that the public may see things a little differently.  As a student said, you can wake up the sleeping giant, but watch out.  You have no idea where and how things go from there.  (Not to overstate the obvious, but in this case, the sleeping giant is the collective general public which of course includes its media, legislation, regulation, and litigation constituents.

 I can see three outcomes; either this will fade away as a plan in which no one is interested, or it will force laboratories to re-look and re-consider their report writing policies and practices, or the litigators and regulators will have a field day.

So we will see.  Direct to patient reporting – the new normal, or the newly normal, or the beginning of a new “long and winding road that will lead to your door and never disappear”?

Who says that the road to quality improvement is always supposed to be easy.

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