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On the Road to Understanding


ThinkstockPhotos 643870680 webEveryone has a story of how they have impacted patient care in the laboratory.  What about you?  The ASCLS Promotion of the Profession Committee (PPC) wants you to share your story.

As laboratorians, we want to know that other members of the healthcare team understand and appreciate our role in patient care.  We play a huge part in patient safety.  We see situations every day where laboratory tests are being overutilized, underultilized, misinterpreted or just ignored.  It is up to US to be the voice for these patients.  Who better to consult with other health care professionals about laboratory results than those of us who live and breathe laboratory testing every day?  Indeed, there are already many of you out there who are doing just that:  Having those critical conversations with doctors and nurses on the floors, units, clinics, etc.  We offer patient safety resources to help cultivate these conversations.  Visit our Patient Safety website for more information.

Hearing your story might help empower someone else in the laboratory to take that first step out of the lab and into this role of patient advocate and lab consultant.  The PPC is kicking off a yearlong campaign to promote and encourage these conversations.  We would like to mark the miles from our 2017 Annual Meeting in San Diego to the 2018 Annual Meeting in Chicago by documenting these critical conversations.  It is 2080 miles from San Diego to Chicago.  Each conversation will be logged throughout the year and will bring us closer to Chicago with our ultimate destination of recognition and understanding.   With San Diego in close proximity to Route 66, we are going to follow this road and highlight attractions along the way as we reach milestones.

Share Your Story

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Complete this form, and tell your story of how you educated or elevated our profession to another healthcare collegue, such as explaining why a specimen must be collected correctly, the consequences of skipped or ignore quality control or other important topics.  Describe an interaction where the laboratory's role in patient care was emphasized.

Each story will be equivalent to one mile on the road from San Diego to Chicago.  We will mark these miles on a map displayed on the front page of the ASCLS website.  Everyone will be able to keep track of our progress.  ANY laboratorian can enter a conversation, not just an ASCLS member.  Refer your friends and fellow lab mates!

 The more stories, the easier our travels will be.  So tell us your story today!

Your Voice, Your Story: Read How Laboratory Professionals Have Impacted Patient Care

We opened a new facility and there were some issues with our pneumatic tube system and its functionality with the users in the OR. The OR system required that each user have a unique access code and we soon found out that not all users had been identified. Thus, there were times of delay while an ID'ed user was found. This caused some samples to have a delay of several minutes between collection and receipt into the laboratory.

In a discussion about this problem it was identified by the OR staff that this was leading to an increase in clotted samples and the need to redraw. This in turn led to a great discussion with OR staff who did blood collection as to why this pneumatic tube delay was not the culprit increasing the issue of clotted specimens, but it was a function of the drawing and handling process of the samples themselves at the point of collection.

This discussion was then taken back to OR staff who were responsible for collections and the % clotted samples has basically decreased to 1%.

It is so easy for staff outside the laboratory to make an assumption when a process is going awry. And in turn so easy to derail that assumption with valid reasons - the "why's" - behind the true impact to the process. The lab is the conduit of those "why's" so let the education and info flow!

On a Friday afternoon, five minutes away from clocking out a three year old little boy was sent to the clinic for a blood draw. I had just sent my phlebotomist home for the weekend. The little boy's mother informed me, this was his first blood draw and he has been extremely fussy lately. The provider listed a diagnosis of fatigue and slight bruising. Fortunately, I was successful in retrieving a blood sample for a CBC. The peripheral smear was 87% blast along with a white blood cell count of 100,000. The family was set to go to vacation in Florida that day. The little boy was treated admitted and began treatment that night.

While reviewing orders for a NICU baby (at 2am no less), I discovered an order for a serum protein electrophoresis. I was puzzled as to why a provider would order such a test on a newborn. I looked for further details on the young patient and found that the neonatologists were considering that the baby may have a hemoglobinopathy.  I realized that the serum protein electrophoresis order was likely placed in error, and a hemoglobin electrophoresis was indicated instead. I called the patient's nurse, explained the issue, and had her change the order before she drew any of the baby's lab work. With my knowledge of laboratory science, I was able to prevent that baby from needing to be redrawn for that hemoglobin electrophoresis and prevented one more headache for nursing and lab staff.

A Medical Laboratory Scientist (MLS) received a phone call in the Coagulation Lab from a physician. The physician was concerned about an International Normalized Ratio (INR) result of 18 on an outpatient. The INR testing was done in another lab. The physician mentioned that the patient was on coumadin. The physician had spoken with the patient's husband about the coumadin dosage. The husband indicated that the patient did not change the coumadin dosage, did not miss a dose and was not overdosed. The physician also mentioned that the patient's INR blood specimen was collected right after dialysis. The physician asked the MLS if the after-dialysis blood collection would cause the INR result of 18. Heparin was used in dialysis. The MLS explained that a blood specimen containing an excessive amount of heparin could falsely elevate the INR result, but likely not elevate to an INR of 18 that high. The physician took the MLS's suggestion to have the patient's INR rechecked with a new blood specimen the next day.

An activated partial thromboplastin time (aPTT) test was completed on an inpatient blood specimen. The result was very high, over the test's upper testing range. The blood specimen was not clotted. In investigating the reason behind the very high aPTT result, the Medical Laboratory Scientist (MLS) did an Anti-Xa assay (Anti-10a, Anti Ten a, Anti coagulation factor 10 a). The Anti-Xa assay result indicated the specimen contained an excessive amount of heparin, the likely cause of the very high aPTT result. The blood specimen was a nurse-collect. The patient's nurse was consulted as to whether the patient was on any anti-coagulant. The nurse indicated that the patient was not on any anti-coagulant. The MLS then specificially asked if the patient had been on heparin. The nurse mentioned that the patient's IV line was dealt with with heparin. The aPTT blood specimen was collected from the line. Based on these findings, the MLS concluded and explained to the nurse that the aPTT blood specimen was likely contaminated with heparin, causing the very high aPTT result. A subsequent re-collect blood specimen for aPTT was obtained from the patient. The aPTT result was in the normal reference range.

A Medical Laboratory Scientist (MLS) answered a phone call from a physician to add on a test to a cerebrospinal fluid (CSF) specimen. Upon ending the phone conversation, the MLS went to the computer to add on the test. The MLS noticed that the add-on lab test was put in incorrectly in the computer; the specimen type was ordered as "blood". The MLS corrected the physician's mistake and edited the test to the correct CSF specimen type.

When working a weekend shift by myself at one of our urgent care medical offices, I was asked to draw a 7 y.o. male for a CBC. Between me and his dad, we managed to get the blood drawn.  During that encounter, the dad recounted the story of his week.  His son was screaming when touched, running a slight fever and was very cranky. He mentioned this was their third time to the urgent care.  The dad was told repeatedly it was the flu, but he knew it was something more. I asked if blood had been taken on previous visits, and he said "no."  I ran the CBC, nothing too remarkable.  When I looked at the differential, I almost screamed. Marked aniso and poikilocytosis! Did I mention the race of the child? You guessed it....Sickle Cell Crisis! I made a quick call to the ER doctor reporting the findings and urging him to put the patient on oxygen.  This child was in Sickle Cell crisis.  The doctor yelled, "Get the O2 and call Children's Hospital STAT!" I knew at that moment that I had truly made a difference! This incident happened over 15 years ago, but I use it every time I need to impress upon a group of middle school or high school students the importance of our profession!

At the time of this story, our lab was using the Toxi-Lab chromatography method for performing drug screens. It was a Saturday morning when a patient came into the emergency room in respiratory distress.  The nursing staff had to resuscitate this patient multiple times. The physician was not sure what he was dealing with, so he ordered a drug screen to see if that would give him any answers. The drug screen report indicated the presence of strychnine. When the physician reviewed the treatment for this, it was different from other drug overdoses, and based on this report, he treated and saved this patient. It was later determined that it was an attempted homicide, in which, the husband had placed the poison in the patient's Tylenol capsules. Without this report, this patient would most likely had died, and the physician would not have been able to treat the patient properly. It was a very memorable and rewarding moment in my lab career.

As a younger manager, I was working with a small team to help improve patient throughput in the Emergency Department. After meeting for several weeks, the group had developed a good relationship with each other, so I was pleased when the ED Provider on the team reached out to me with her concerns that the tech who runs the Troponin tests was not doing as well as the techs who run the Hemograms and Chemistry profiles. She was getting those results in 30-minutes or less, and it was taking 45-60 minutes for the Troponin. This was a great opportunity to educate others about the magic black box technology that seems to be an all too pervasive view of the laboratory department. Our next meeting was a tour of the laboratory where we followed the specimens from an ED patient through the lab. It was a huge eye-opener for the whole group and resulted in a renewed focus on workflow from the time the patient arrives and how to make sure all hand-offs flowed smoothly.

60 yo. Male no personal physician came to ER three nights in a row with elevated WBC and lymphocytosis. Few smudge cells and occasional ATL. Different physician saw him each night. Each ordered a monotest and sent the patient home. Third time I did the differential, I called ER. I explained that I was not a physician so could not officially report the sample as CLL but my twenty plus years of experience told me that's what it was. Within the hour, the hematologist came to the lab, looked at the slide for about thirty seconds and admitted the patient as CLL. Patient started on treatment that night.

In September 2015, the National Academy of Medicine, formerly the Institute of Medicine, issued a report on diagnostic error in America. The principal conclusion is that every adult American experiences at least one diagnostic error in a lifetime. One of the major contributing factors to diagnostic error is the failure to order the correct diagnostic tests. There is often significant controversy, even among experts about which tests should be included and which ones excluded from a laboratory evaluation. Generalizations are often made about test use by individuals, not a group of experts. We completed a study with the rare opportunity to have multiple experts in diagnostic coagulation and hear the clinical presentation of patients who are being evaluated in real time for bleeding or thrombotic disorders. These experts were able to provide an opinion about overutilization or underutilization of coagulation laboratory tests on a case-by-case basis in real time. The results of this study indicate that experts hearing cases in clinical context, found that overutilization and underutilization of laboratory tests pertaining to coagulation testing were present in about 78% of the cases, with 44% due to underutilization, 16% due to overutilization, and about 18% due to both. This causes an immense financial burden to a healthcare facility, and can cause serious clinical consequences. The use of patient specific, expert driven interpretive comments by a diagnostic management team accompanying laboratory results helps physicians to more accurately request the correct, and only the correct laboratory tests reducing delayed or missed diagnosis.

I am a student in the chemistry department as part of my senior year rotations. This week the ER was running low on green top tubes so received a few calls from the nurses asking if tests such as metabolic panels could be run on yellow top tubes just the same as green tops. A nurse asked if a lactic acid or ammonia could be run on a yellow top, and by our protocol we answered, "No." She asked the same question to the phlebotomy department which promptly transferred the call back to us. I answered feelling like she was more so wondering WHY they had to use green top for these tests. I explained that if the tube hasn't fully clotted and there is any fibrin left in the serum when the tube is tested that it will interfere with the tests to give bad results. This was my first time answering a nurse's question and feeling like I had shed some light o a point of confusion! Looking forward to more opportunities for sharing information with nurses and doctors in the future!

I was working in the Transfusion Service of a large hospital. We had been transfusing a patient with cryosupernate (cryo-poor plasma) for several weeks. Then we received an order to transfuse with two units of cryoprecipitate. I called the nursing unit to verify the order. The nurse confirmed the order and I asked her to verify with the ordering physician. A few moments later, an irate resident called and wanted to know why his orders were being questioned. I explained that we had been transfusing with cryo-poor plasma for several weeks. I asked him to clarify the order with the patient's attending physician. About 5 minutes later I again spoke with the resident who was very apologetic. He cancelled the previous order and stated that it should have been for cryosupernate. He then stated, "cryoprecipitate, cryosupernate, what's the difference?" I proceeded to explain the difference: cryosupernate was plasma with the cryoprecipitate (clotting factors) removed. The resident thanked me for the information and for questioning the order which prevented possible harm to the patient.

Several years ago, our Hematology Department was working up a peripheral blood specimen for CBCD and Reticulocyte count prior to a bone marrow aspiration. The reason for the bone marrow was extreme thrombocytopenia. The specimen collected in our lab yielded a normal platelet count, so we contacted the physician.  A recollect was submitted verifying our normal count was correct. The oncologist contacted the phlebotomy collection lab at an outside vendor to track the initial error. We had already discussed with the oncologists the possibility of improper collection with a clotted specimen. The initial sample that was used to refer the patient to the oncologist was indeed clotted. We saved a person from having to undergo an unnecessary invasive technique and additional expense not to mention undue stress.

In participating in a local church's healthfair in May 2017, I did a glucose on a gentleman, and it came back as greater than 500 mg/dL! I did not let him leave until we contacted the church's nurse who would do the follow-up. Interestingly, the gentleman had an insulin pen which he promptly injected into himself right then and there!!





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