My passion for medicine was fueled by a desire to make a difference. During first year of medical school, I learned that this pursuit extends beyond solving medical problems. Quality improvement in health care is a fundamental tool for impacting positive change.
When a pediatric patient in the intensive care unit at The Hospital for Sick Children (SickKids) was inappropriately treated for low potassium due to a mislabelled blood specimen received by the lab, everyone paid attention. Located in Toronto, Ontario, SickKids Hospital treats over 215,000 children each year and serves as a national leader in delivering world-class quality and service. Making a difference means optimizing health care processes in order to recognize the potential for medical errors before these risks ever become a reality.
Fortunately, this patient did not suffer serious consequences. The potential for harm, however, inspired me to pursue quality improvement work for preventing future errors. As part of the Institute for Healthcare Improvement (IHI) Open School Chapter at the University of Toronto, I collaborated with the quality improvement and clinical teams at SickKids, and led an interprofessional team comprising medicine, nursing, and engineering students. The focus of our work was reducing the rate of mislabelled specimens in the Pediatric Intensive Care Unit (PICU) and Cardiac Critical Care Unit (CCCU).
Safety reports from 2013 revealed that mislabelled specimens posed a preventable risk in these departments. Each month, over 3,000 specimens were sent to the lab. The monthly incidence of mislabelled specimens in PICU/CCCU was twice the hospital target. The root cause of the problem related to the involvement of multiple staff members in the blood collection process.
In order to effectively address these issues, we recognized that frontline staff engagement is vital for implementing sustainable change. Therefore, we assembled a multidisciplinary Mislabelled Specimen Team. Using input and support from frontline clinical staff, we designed the One-Person-Process (OPP) – a standardized work protocol in which the blood collection process would be carried out by one person, from start to finish. We aimed to reduce the rate of mislabelled specimens by 50% from baseline within a 12-month time period.
Through several PDSA cycles, we optimized the process in order to improve patient safety and efficiency. Our primary endpoints were the number of monthly mislabelled specimens, and the frequency of blood collections using the OPP protocol. At the end of six months, the number of mislabelled specimens decreased by 50%, and the frequency of blood collections successfully completed by one person increased by 32%.
This project taught me that engagement of frontline staff provides a fertile climate for improving quality and patient safety. In addition, staff-driven solutions, peer-to-peer education, and ongoing evaluations are powerful tools for generating change. I continue to pursue my passion for quality improvement and patient safety with IHI, in addition to serving on quality improvement committees for outreach clinics in Toronto. I am confident that these experiences will strengthen my ability to deliver effective care to future communities.
