Quality Tools and Strategy for Critical Alerts Process Improvements to Ensure Patient Safety

Abstract

Objectives A number of regulatory and accrediting bodies require the reporting of critical results on a timely basis (immediately or within the time frame established by the laboratory) to “the responsible, licensed caregiver” as timely notification of critical laboratory results can pivotally affect patient outcome. The aim of the study was to decrease the turnaround time (TAT) of critical result notification along with assurance of notification to the concerned caregiver or clinicians. The objectives was 30% reduction in the critical value notification TAT and identify factors associated with delayed reporting and root cause analysis for these factors by application of quality tools.

Materials and Methods The study was conducted at the Institute of Human Behavior and Allied Sciences, Delhi, a tertiary center teaching Hospital, from April 2019 to June 2021. A value streamed Process Map of critical alert was prepared. The incidents related to failure were presented through Pareto chart. The possible causes were analyzed through the fishbone model. The failure mode prioritization was executed with Failure Mode and Effect Analysis (FMEA). Through extensive brainstorming, appropriate and feasible corrective actions were implemented. The effectiveness of the implemented plan was analyzed by reassessing the TAT of critical alert and feedback received by clinical caregivers.

Results After implementation of corrective action plan using quality tools for 3 months, the average critical alert TAT was reduced to 21 minutes from 30 minutes (30% reduction). The median critical alert TAT for ICU, emergency, and IPD were reduced to 3 minutes (IQR: 1–7). During the pilot project, 156 critical value data were sent for feedback with treatment plan but was received only for 88 patients (56%).

Conclusion Comprehensive utilization of quality tools has a potential role in patient safety by reducing the critical alert TAT as well as establishing an effective communication between laboratory personnel and clinicians.

Keywords

critical value - quality tools - FMEA - process map - Pareto chart - fishbone model

Authors' Contributions

Rachna Agarwal contributed to the conception and design and revising it critically for important intellectual content.

Puja Kumari Jha contributed to the conception and design, acquisition of data, or analysis and interpretation of data and drafting the manuscript.

Ethical Approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the Institutional Research Committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Publication History

Article published online:
28 June 2022

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