By Bob Browning and Brenda Henderson

When it comes to protecting patients’ safety and preventing medical errors in hospitals, most of the focus today is on improving human processes. These approaches include better systems for reporting errors, better analyses of errors that occur, and better use of information about errors to prevent similar problems in the future.

le01.jpg (16508 bytes)Beckman Coulter’s Power Processor pre-analytical system

In the hospital laboratory, an additional priority is emerging. Medical errors can originate in labs if patient samples are mislabeled, if results are inaccurate or if information doesn’t reach physicians before they need to make crucial treatment decisions. Preventing these mishaps depends at least as much on upgrading mechanical processes as human ones. That is, lab automation is proving to play an indispensable role in maximizing patient safety.

At Baptist Hospital of East Tennessee in Knoxville, we took a major step-up in automation as part of a hospital-wide lab renovation project. Automation has dramatically improved the quality and consistency of our results, the accuracy of our labeling and information reporting, and the test turnaround time (TAT) for getting results into physicians’ hands. All of these factors directly affect the welfare of our patients and reduce the likelihood of error.

Our project has also made our lab a much better — and safer — place to work. Plus, the financial savings it has generated demonstrate that, when done wisely, automation pays for itself and is an investment, not an expense. We believe our experience, as detailed below, provides a useful template that other labs can follow with similar success.

Automation: the patient safety angle
In late 1997, Baptist Hospital began planning a renovation of its laboratories to take advantage of new advances in lab instrumentation. Our strategy included three main elements: first, moving all workstations in the same “process chain” into a single, open space; second, increasing the capacity of our analytical instruments; and third, installing pre-analytic robotics.

Because we wanted our new instruments to interface easily with each other, the instruments we were retaining, and our laboratory information system (LIS), it made sense to reduce the variables by using a single vendor’s products. We also wanted to use a vendor with the technology to meet both our analytic and automation requirements.

The new lab was fully operational in July 2000 and features Beckman Coulter’s Power Processor automation system for sample-handling tasks, two Synchron LX20 clinical systems for general chemistry, three Access immunoassay systems, two Coulter Gen.S hematology analyzers and Electra 1600 and 1400 coagulation analyzers. The broad test menus of the instruments, plus DataLink data management software that ties together the instruments (in our case, we’ve used it with our LX 20s and our Accesses) into a single workstation, enabled us to consolidate workstations to a greater degree and also streamline our workflow. The “open lab” design made it possible for us to process nearly all of our work in one space, instead of shuttling it around the hospital from one specialty lab to another.

Starting from the pre-analytical phase of our sample processing, this approach has improved the laboratory’s contribution to patient safety. When performed by technologists and without the aid of automation, the pre-analytic tasks in a clinical lab are the most labor-intensive phase of testing and thus the phase most prone to human error. At best, mislabeled or lost test tubes, tubes that are sorted to the wrong analyzer, and ordinary human variability create confusion and delays that slow down TAT. At worst, results are reported for the wrong patient, leading to improper treatment.

Pre-analytical tasks also tend to be among the most mundane jobs in the lab, so technologists may occasionally lose focus while doing them and make mistakes. In today’s pressure-packed environment, where labs are handling growing workloads with as lean as possible staffs, the physical and mental fatigue also leads to errors.

Our pre-analytical automation system has greatly reduced all of these problems, by cutting our manual sample handling by 50 percent. The automation system doesn’t get bored, tired or stressed, and it does its job the same way, in the same time span, day in and day out. Not only has its efficiency wrung errors out of the system, but it has also contributed to the substantial gains we’ve made in TAT (see below).

Moving on to the analytic phase, it’s a given that today’s automated analyzers have improved patient safety by reliably and accurately performing the bulk of tests a hospital lab needs to do. But this is just a starting point.

For instance, the broad test menus of our analyzers, combined with our workstation consolidation and open lab, have eliminated about 90 percent of our aliquotting. This, too, reduces human error by reducing manual sample handling, including the not-unheard-of error of combining two patients’ samples in one tube.

Through interactions between our LIS and our analyzers, we also autoverify our results, which affects patient safety in several ways. First, consider the impact on TAT. Before we began autoverifying, every sample had to be manually reviewed at a workstation. Now, some 80 percent to 85 percent of our samples are autoverified and the results are released automatically. Along with the previously mentioned contributions of the pre-analytical automation, this has dropped TAT on our five most frequent tests from 49.2 minutes to 18.9 minutes, a total improvement of more than 60 percent. Perhaps more importantly, the TAT on our outlier tests at the 90th percentile ( i.e., those tests where something has gone wrong and must be corrected) has fallen from 72.2 to about 33 minutes.

This means that physicians are far less likely to have to treat an emergency patient without the proper data at hand. Autoverification also frees up technologists to concentrate more fully on those remaining 15 percent to 20 percent of samples that must be manually reviewed. That increases the quality of those results, another boon for patient safety. In addition, processing variations such as corrected reports are down 48 percent in our lab, because automation has taken over so many menial tasks and given staff the time to do things the proper way.

Lab safety benefits of automation
Unlike patients, for whom lab safety gains may be invisible, our staff is well aware of how automation is changing their lives, and they are quite pleased because our project has made them safer, too. Their exposure to biohazards such as splashed or spilled samples or broken test tubes is down 25 percent because instruments have taken over so much of the sample handling. They also have more time to be careful in their work. With the system de-capping tubes for them, they are far less likely to suffer repetitive motion injuries, as well.

Automation has also made the lab more worker-friendly, a benefit to management almost as much as staff, because we’re retaining staff longer and finding it easier to attract new employees, who appreciate our well-equipped environment. In a market where good technologists are in scarce supply, this gives us a competitive staffing advantage. Morale is up, too. Automation has made it easier for staff to do error-free work, and they feel better about their jobs as a result.

As for the financial side of automation, the savings we’ve realized have been extensive. This project dropped our expenses by $347,000 per year. That is a decrease of between 7 percent and 8 percent in test expense per reportable result, primarily because of salary savings. We are now operating with 11.2 fewer FTEs on paper (in reality, 12.2), because one technologist is being trained to become our next LIS manager. Yet with this smaller staff (reduced entirely through attrition), throughput has grown. Productivity as measured in reportable results per paid hour is up 13 percent.

Bob Browning is director for laboratory services at Baptist Hospital of East Tennessee. Brenda Henderson is the hospital’s clinical laboratory operations manager. Together, they planned and oversaw the laboratory renovation project.