In this episode of eLABorate Topics podcast Lona Small, discussed the old way of approaching errors in the lab and the new way of system thinking as a way to reduce errors. Lona discussed the old approach of only focusing on the person involved in the error. She showed that remedial retraining does not solve patient safety errors unless lack of training was found as the root cause.

Lona mentioned the many factors involved in system thinking such as Patient (acuity, age etc.), Care team (including family), Organization (infrastructure layout, hospital or clinic, lab), and Environment (regulatory etc.)

She discussed the steps to take involving system thinking when there is a lab error.

1. Consider the system design.

2. Talk to your team to understand all possible system design factors that could cause errors (gather data).

3. Meet with other care teams outside of your team that are part of the affected system.

4. Together discuss your findings.

5. Together identify flaws in the system that could have caused the error ( people, process, infrastructure, environment)

6. Discuss solutions and understand how changes could affect each other ( unintended consequences).

7. Make changes and monitor.

8. If error is reduced, create new workflow, procedure or document new policy.

9. Continue to monitor.

NOTE- there is no error free lab.

For a quick guide to help you start stepping out of the lab and working with other teams as part of the system thinking.

Use this gift: 5 Baby Steps out of the Basement- Resulting in Giant Leaps To The Executive Suite https://www.lonasmall.com/pl/133013

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