Aurora St. Luke's Medical Center

Presentation Notes

Poster presented at: 2019 Advocate Aurora Health Nursing Science Conference; September 18, 2019; Wheeling, IL.


Introduction: At the end of 2016, the St. Luke’s Medical Center Safety Advocate Committee reviewed incident report data and discovered that diagnostic testing-lab was the category with the largest opportunity for improvement. “Collaboration among healthcare providers is considered an essential attribute of the work environment and a core competent of the patient safety culture” (Ma, Park, & Shang, 2018, p.1).

Purpose/Objective: An inter-professional team formed to identify and address the root causes of lab-nursing incident reports, thus improving process and patient outcomes.

Method/Evaluation: The team utilized process mapping and PDSA quality improvement methodology to describe the lab draw process and address priority issues. Changes to the lab draw process included communication tools between lab and nursing, utilization of a swarm process to draw labs in a timely fashion, and staffing changes in phlebotomy to support timely completion. Lab shift supervisors implemented daily huddles to improve responsiveness and impact the timeliness of lab draws.

Results/Findings: Incident reports involving the lab draw process reduced from 2,307 in 2016 to 1,424 in 2018 with sustained improvement into 2019. Decrease in total number of lab incident reports along with lab incident reports making up a much smaller percentage of total incident reports. Morning lab completion time, STAT lab time, and timed draw efficiency all outperformed their targets.

Discussion/Conclusion: The committee has improved on all identified objectives including incident reports and draw time metrics. For the first time, all draw time goals were met in May, 2019.

Implications for Practice: Collaboration among disciplines propels patient outcomes forward by removing interprofessional barriers. Formation of a lab-nursing collaborative has improved communication, compliance with practice standards, and outcomes for patients.

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