German: Panning for Gold in a ‘Just Culture’

March 2015
ADVANCE for Administrators of the Laboratory
“Panning for Gold in a ‘Just Culture’;
Nonconforming event reporting as a quality management cornerstone
By Randy German, MT(ASCP)SBB—Blood Bank and Laboratory Quality Manager
Hoag Memorial Hospital Presbyterian (Newport Beach, Calif.)

“The College of American Pathologists (CAP) requires tracking and trending nonconforming events (NCEs); FDA requires blood-product deviations reporting. Laboratories are also required to develop Key Indicators of Quality (KIQs) metrics-essential components of a Quality Plan. Done effectively, in a ‘Just Culture’ setting, NCE and BPD reporting can be the cornerstone of an effective quality program. Done ineffectively, NCE and BPD reporting can be time consuming and contribute to low morale.”

To help administrators implement an effective program, German reviews NCE and BPD reporting regulatory requirements, how to conduct effective root-cause analysis in a “Just Culture” setting, how NCE trending can help guide selection of  KIQs, and the benefits of NCE-reporting software. He also emphasizes the benefits of electronic reporting:

“In 2006, following a BPD reporting-related FDA citation, we realized our paper NCE system was inadequate and went live on Nouvation’s OTIS-Blood Bank. In 2011 we implemented Nouvation’s OTIS-Laboratory product for NCE reporting in the general laboratory.

“With paperless reporting, OTIS ensures completeness of reports, guides RCA and corrective actions, allows for custom coding and risk stratification, captures employee discussion and staff notices and helps to ensure BPD reporting within the allowable 45-day time frame.

“Intuitive ‘click-view’ functionality allows instant trend analysis by virtually any data field, providing invaluable trending data that guide choice of quality improvement and compliance initiatives most critical to the Laboratory. In contrast, obtaining trending data from our legacy paper system was challenging and time consuming.”

Randy German at HoagGerman concludes:

“A robust NCE reporting system within a ‘Just Culture’ can provide a gold mine of information, particularly when you use an electronic system with easy trending capability. The nuggets mined from your NCE data can be a cornerstone of your quality system and help achieve the ultimate goal of preventing patient harm.”

Click on ADVANCE/Randy German: “Panning for Gold” for the full article. 


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