Medical Error Prevention: Patient Safety

(based on 3290 customer ratings)

Author: Garland E. Pendergraph, PhD, JD, MLS(ASCP)SM, HCLD/CC(ABB)
Reviewers: Julie Ann West, PhD, MLS(ASCP)CMSMCM and Joshua J. Cannon, MS, MLS(ASCP)CMSHCM

Medical Error Prevention is a comprehensive course that includes potential causes of medical errors in the clinical laboratory, important legislation and definitions, and steps laboratorians can take to reduce the impact of medical errors in their workplace. This course is an ideal part of an effective medical error reduction program and is appropriate for both experienced and novice laboratorians.

Continuing Education Credits

Objectives

  • List and describe the six aims of the National Academy of Medicine to improve the quality of health care.
  • Describe the National Academy of Medicine aims within the context of quality clinical laboratory services.
  • Define "total testing process" and recognize errors that could occur in each phase.
  • Identify outcomes of patient safety errors with respect to clinical laboratory services.
  • Discuss patient safety goals.

Course Outline

  • Six Aims of the National Academy of Medicine to Improve the Quality of Health Care
      • State of Quality in Health Care
      • Six Domains of Quality in Healthcare as Defined by the National Academy of Medicine
      • Improving Effectiveness
      • Patient-centered Care and Timeliness
      • Preventing Medical Errors Through Patient Involvement
      • Efficiency and Equity
      • According to the National Academy of Medicine, quality health care systems in the United States should be:
      • One way patients and their families can become active participants in their health care is by:
  • The National Academy of Medicine Aims Within the Context of Quality Clinical Laboratory Services
      • Clinical Laboratory Services and Safety
      • Which of the following options related to clinical laboratory services is unlikely to cause patient harm?
      • Clinical Laboratory Services and Effectiveness
      • Clinical Laboratory Services and Patient-Centered Care
      • Clinical Laboratory Services and Timeliness
      • Clinical Laboratory Services and Efficiency
      • Clinical Laboratory Services and Equity
      • Which of the following best defines effective clinical laboratory services?
      • How might a laboratory ensure equity in laboratory testing services?
  • Recognizing Errors that Could Occur in Each Phase of the Total Testing Process
      • Medical Errors
      • Which of the following options is an error of omission?
      • Total Testing Process
      • Safe Pre-Examination Component of Total Testing Process
      • Safe Examination Component of Total Testing Process
      • Safe Post-Examination Component of Total Testing Process
      • Patient-Centered Pre-Examination Component of Total Testing Process
      • Patient-Centered Examination Component of Total Testing Process
      • Patient-Centered Post-Examination Component of Total Testing Process
      • Identify the phase of the total testing process in which each error occurs.
      • Misinterpretation of an alphabetic flag in the result field, such as using a lowercase letter L (l) to indicate a low result, where the result could b...
  • Outcomes of Patient Safety Errors with Respect to Clinical Laboratory Services
      • Outcomes of Laboratory Services
      • The Laboratory Quality Management System and Non-Conforming Events
      • Reportable Errors
      • Reporting of Errors
      • NCEs of External Origin
      • NCEs of Internal Origin
      • Root Cause Analysis
      • Root Cause Analysis, continued
      • Management of Non-Conforming Events
      • RCA Example: Cause-and-Effect Diagram
      • Failure Mode and Effect Analysis
      • Five Whys
      • A patient event occurs that results in a near miss. Which of the following is an appropriate response to improve the process involved and patient safe...
      • NCEs may be of external or internal origin. From the answer choices, choose the NCE of internal origin.
  • Sources of Data to Identify Errors and Patient Outcomes
      • Monitoring Laboratory Processes to Prevent Medical Errors
      • Data Sources to Identify Errors
      • All of the following sources may be useful for identifying patient safety problems except:
  • Patient Safety Goals
      • The Joint Commission 2025 National Patient Safety Goals for Clinical Laboratories
      • National Patient Safety Goal: Identify Patients Correctly
      • Which of the following is not an acceptable patient identifier to use prior to performing venipuncture procedures?
      • National Patient Safety Goal: Improve Staff Communication
      • National Patient Safety Goal: Prevent Infection Through Hand Hygiene
      • What is generally considered the single most important procedure for preventing the spread of healthcare-associated infection?
  • References
      • References

Additional Information

Level of Instruction: Intermediate
Intended Audience: Medical laboratory scientists, medical laboratory technicians, laboratory supervisors, and laboratory managers. This course is also appropriate for MLS and MLT students and pathology residents.
Author: Garland E. Pendergraph, PhD, JD, MLS(ASCP)SM, HCLD/CC(ABB) received his MSPH from the University of Kentucky in Lexington, his PhD in medical parasitology/entomology and mycology from the University of North Carolina in Chapel Hill and his law degree with a concentration in health care law from Concord Law School, Purdue University. He also did a fellowship in Tropical Medicine at Louisiana State University School of Medicine. He is the author of a textbook on phlebotomy, a number of scientific articles, plus internet training programs. He is the director of five laboratories.
The author has no conflict of interest to disclose.  
Reviewers:
Dr. Julie Ann West, PhD, MLS(ASCP)CMSMCM is certified by the American Society for Clinical Pathology Board of Certification (ASCP BOC) as a Medical Laboratory Scientist (MLS) and Specialist in Microbiology (SM). In addition, Dr. West has earned a PhD in Public Health, Epidemiology Specialization with emphasis on infectious diseases and a Certified in Public Health (CPH) certification by the National Board of Public Health Examiners. Dr. West is experienced as a technical specialist, safety officer, educator, and lead in the Veterans Health Administration healthcare system, and has prior experience as an administrative laboratory director.

Joshua J. Cannon, MS, MLS(ASCP)CMSHCM received his Bachelor of Science and Master of Science in Medical Laboratory Science from Thomas Jefferson University in Philadelphia, PA. He holds Medical Laboratory Scientist and Specialist in Hematology certifications through the ASCP Board of Certification. He was a professor at Thomas Jefferson University for seven years before transitioning into his current role as Education Developer at MediaLab by Vastian. His areas of expertise and professional passions include clinical hematology and interprofessional education.

This course is part of:
Male handwashing 400
Elements of the CAPA process shutterstock and text added
110220 fishbone edit
110220 NAM-01