The Use of Debriefing Tools and Education of Staff to Reduce ABG Scanning or Labeling Errors

Abstract

Background:

Could the Respiratory Therapy department reduce the number of ABG scanning and labeling errors through education and a debriefing tool? The hypothesis is that ABG scanning and labeling errors could be reduced with awareness and staff education. The baseline for ABG scanning and labeling errors in August 2017 was 24 scanning or labeling errors during that month, resulting in a 0.66% error rate. 24 errors in a month meant there were 24 patient ABG's that did not post to the electronic chart in a timely manner or could potentially post to another patient's electronic chart. This is a potential for delayed patient care if the ABG did not appear in the patient's chart, or if the ABG results ended up in another patients chart, the results could be acted upon with the wrong patient.

Methods:

A high rate of ABG errors was noted by the leadership of the Respiratory Therapy department. A fishbone was done to determine possible causes. A baseline ABG error rate was established using August 2017 data. The error rate was obtained by taking the number of ABG scanning or labeling errors and dividing by the number of ABG samples analyzed by members of the Respiratory Care department. A debriefing form, developed based on the fishbone, was utilized to determine the cause of each ABG scanning or labeling error. This form was used for staff with every ABG error. Interventions, such as creation of a quiet zone around the blood gas analyzer, were designed based on the findings in the debriefing form. Data was presented at each monthly staff meeting with an emphasis on error rate for each month, causes of the errors noted, and the progress of reduction in the error rate. The goal was to reduce the error rate from 0.66% to 0.5% or less.

Results:

Debriefing with each employee to determine the error cause and presentations at staff meetings to educate the Respiratory Therapy staff resulted in a reduction of ABG scanning and labeling errors to 0.05% which was sustained in both March and April of 2018.

Conclusions:

The reduction in ABG scanning and labeling errors shows that use of a debriefing tool and staff education at monthly staff meetings was an effective way to reduce errors, thus increasing accuracy and timeliness of ABG results being available for the medical team to determine treatment.

ABG error data from August 2017 to April 2018