The first time she called the safety alert system at St. Paul’s Hospital, Deb Berscheid was a little apprehensive. “I didn’t really know what to expect, although after using the AEMS system I had a good idea what information they would need,” she says.

Joanne Anderson (left) and Deb Berscheid (right) in the lab at St. Paul’s Hospital

Joanne Anderson (left) and Deb Berscheid (right) in the lab at St. Paul’s Hospital

Berscheid, a medical laboratory technologist with the Laboratory’s department of Hematology, was calling to report a tote of specimens that was incorrectly labelled, which could have caused those specimens to go to another department, delaying testing. “I brought it to the attention of another staff member and together we fixed it and then called to report it.”

That, according to Victoria Schmid, Director Safety Alert System, is exactly how the system is supposed to work. “We know that the people best suited to solve problems in a unit or department are the people who work there,” she says. “When the problem is potentially harmful to a patient or staff member and requires more help, that’s when we can provide additional support and response in the form of a director or vice president.”

Berscheid soon realized her apprehension was unnecessary. “The safety centre staff are amazing,” she says. “They’re knowledgeable, friendly, and receptive and our staff really appreciates the fact that the coordinators prompt some pertinent questions that spark the need for some more information to be given. Plus, having the coordinator repeat back exactly what you’ve said really clarifies what you’re expressing because sometimes it may have been worded incorrectly or inappropriately the first time.”

As a result of reporting safety issues, two mistake proofing projects have been initiated by the Intensive Care Unit at St. Paul’s Hospital and the lab is collaboratively involved in this work. The lab identified a high incidence of problems with collecting coagulation specimens. “This involves other departments as well, but right now we are mistake proofing with the ICU team because they had a higher rate of ward collected specimen tubes which were inappropriately filled or hemolyzed (i.e. broken red blood cells),” explains Berscheid. “The ICU team has improved education and communication between our two departments because they were unaware of why we were rejecting so many specimens.”

Specimens were rejected because there is a certain blood to plasma ratio that needs to be met in order for the testing to be accurate. An under filled tube will cause false results.

“We’re even working with BD, the company that supplies the citrate tubes. BD is scheduled to come to St. Paul’s Hospital and provide an education session for ICU Staff involving both departments,” says Berscheid.

The lab is also working on ensuring everyone is trained in the standard way of labelling tubes. The lab was reporting an increased amount of mislabeled tubes. “The job instruction breakdown sheet trains everyone on labelling tubes the same way, every time. For the purposes of proper patient identification and proper sample labelling, it is imperative that everyone does it exactly same way,” explains Berscheid. Since implementing TWI, the lab has gone over 100 days without a mislabeling error being reported.

“The most positive outcome of all this is that the concerns that are being reported to the safety alert system are determining how the lab prioritizes its improvements for patient and staff safety,” says Berscheid. “Recently, we realized that the safety centre coordinators aren’t familiar with the acronyms we use every day. So we’ve been working on clarifying how we use ward or department names. It’s been an amazing learning curve for us in the lab as well as for the safety centre coordinators.”

When asked if she has any advice for the facilities that are next on the implementation list, Berscheid says that staff should feel confident and safe in calling the safety centre.

“There is nothing scary about calling and there are no reprimands or repercussions. It really is a positive improvement process in the integrity of patient and staff safety. Staff may find that it might take a little portion of their day to call and file a report, but it’s worth it.”

The safety alert system was built and designed using lean processes and methodologies in December 2013. Since then, the safety alert system team has been hard at work implementing and improving pieces of the initial design.