Better ECG labelling practices help staff get it right the first time

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Better ECG labelling practices help staff get it right the first time

When you’re having a heart attack, there’s no time to waste.

Jocelyn de Hoop, a cardiology technologist, demonstrates how to label and ECG test. Photo credit: Medical Media Services

“The sooner you do the diagnostics, the less damage to the heart,” said Vicki Ehrlich, director, Cardio Services program. “Permanent damage to the heart will keep happening until the patient gets the treatment they need.”

One reason cardiac patients experience care delays seem to be a simple one – staff improperly label electrocardiogram (ECG) tests. ECG and blood test results are necessary to diagnose and begin treatment for a heart attack. If labelling is imprecise, and staff can’t be certain who the test belongs to, the ECG is unusable. The patient will need to have the test redone, causing a delay in care.

Ehrlich knew incorrect labelling was an issue but it wasn’t until she and the other members of her mistake proofing team did an audit in December 2015 that she learned the extent of the matter.

Of 2,371 ECG tests the team examined, 423 lacked key labelling information. Errors include failure to include the patient’s full name, age, medical record number, date of birth, gender, and name and designation of the staff member obtaining the test. That’s nearly an 18 per cent defect rate. This means that, potentially, the care of 18 per cent of patients was delayed because of labelling errors.

“December is not a typical month,” said Ehrlich, recalling the findings. “On average we do between 4,000 and 5,000 ECGs between Pasqua Hospital (PH) and Regina General Hospital (RGH) a month. Further audits showed our error rates ranged between 17 and 33 per cent. During one evening audit, we found all 24 ECGs performed were improperly labelled. It became clear that we had a large problem.”

Ehrlich noted that besides the significant cost to patients, redoing ECG tests can become expensive. Each sheet of thermal paper which the ECG tests are printed on costs about 31 cents. In December 2015, if no ECG mistakes had been made, the cost of thermal paper would have been about $735 for the 2,371 tests. The actual costs were closer to $866. In a typical month, about 4,500 ECGs are performed. If no errors occurred, the thermal paper costs would total about $1,440 per month. Factoring for a 17 per cent rate of error would add $245 to the monthly costs. A 33 per cent rate of error would cost the region an additional $475 per month.

These concerns, along with the knowledge that Enovation – the system used to create the labels – would soon be terminated, spurred Ehrlich and her team to improve the ECG labelling process.

Ehrlich and her team observed that cardiology technologists, whose core responsibilities include performing ECG tests, typically had no labelling defects. The technologists work from 7 a.m. to 11 p.m. daily. For the remaining eight hours, registered nurses at PH and RGH fulfill this role. Ehrlich noticed the nurses were inconsistent in their ECG labelling practices and expects the variance is most likely related to differences in how nurses are taught to obtain ECGs.

To ensure that all those who provide the tests follow the same processes, the project team created work standards and expectations around proper ECG labelling.

“Labelling is expected to occur prior to obtaining the ECG and staff is expected to follow the two-person identifier policy requiring staff to confirm a patient’s identity twice,” said Ehrlich.

The team revised the little-known nursing procedure on how to label ECGs; updated the cleaning practices of the portable ECG cart, machine and cables to ensure they’re consistently cleaned between patients; circulated information on the two-patient identifier policy; and attached brightly coloured stickers to the top of the ECG machines to remind staff doing the tests to label ECG tests with pertinent patient information and their own name and credentials.

To assist staff in tracking where errors originate, the team numbered ECG carts at both PH and RGH according to site and department.

A cardio-neuro educator, who is a cardiology technologist, now leads the training of all new staff. The team created a step-by-step video for staff to observe the labelling process.

The improvements have resulted in big change.

“At our 90-day audit, our defect rate was 5.6 per cent,” said Ehrlich. “This is significant. There are fewer ‘redos,’ staff are working more efficiently, there’s less waste and patients are receiving better quality, safer care.’”

Ehrlich thanks staff in the PH and RGH emergencies as well as staff at the Medical Surveillance Unit (PH), the Cardiac Care Unit (RGH), the Cardiac Surveillance Unit (RGH) and the Surgical Intensive Care Unit for embracing the changes. She also sends big kudos to her team for their enduring commitment to a long-term project. Besides Ehrlich, team members are: Michelle Fisher, Dr. Andrea Lavoie, Dr. Andriyka Papish, Kristin Sali, Laveena Tratch and Kim Voss.


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