Room: 224 AB North
Specimen Errors: Examining the Quality, Patient Safety, and Financial Impacts
Presenter: Phyllis Ragland, RN CPHQ CPPS
Laboratory testing provides essential information for medical decision making. Specimen events can significantly impact Patient Care, Patient Satisfaction, Quality/Safety and Finance, and are often precursors to serious mistakes, including diagnostic errors and inappropriate treatments. The good news is specimen errors are preventable, and effective interventions don't have to be resource intensive. ADNPSO analyzed 3,000 specimen events collected over 4 years, and found 77% of incidents could have been prevented. In October 2018, ADNPSO launched a collaborative Specimen Focused Study aimed at better understanding why specimen events happen and how to reduce errors across the testing process. Study participants will submit Specimen events to ADNPSO for use in deep dive analytics and Rapid PDSA cycles. The presentation will include aggregate results, including baseline data with pre-survey responses, analytic findings, methods used to identify and prioritize corrective actions, and participant feedback from the post-implementation phases.
- Better understand the causation of specimen errors through data collection and analysis occurring in the Pre-Analytical, Analytical, and Post-Analytical Phases of the Specimen Process
- Promote collaboration among participants through learning sessions with federal protections
- Develop recommendations for best-practice patient safety activities
Phyllis Ragland serves as Clinical Patient Safety Advisor for ADN/PSO with 40 years of experience with hands-on clinical and progressive managerial positions in surgical nursing, regulatory preparedness, quality and patient safety in rural and tertiary organizations. She holds credentials of Certified Professional in Healthcare Quality (CPHQ), Certified Professional in Patient Safety (CPPS), Master Trainer - TeamSTEPPSÂ®, and has extensive national expert training on the science/methodologies of patient safety. She has experience as facility expert for Fall and Restraint Management programs; Patient/Family Advisory Council and Safe Patient Handling implementation/coordination program; and Point of Care Coordinator for EHR implementation with processes and outcomes presented at multiple state, regional and national conferences. Ragland co-authored the article, "Implementing a Councilor Model: Process and Outcomes," which was published in the Journal of Nursing Administration.