Primer Part 1 - Preparing a laboratory quality improvement project.

Quality in laboratory medicine encompasses multiple components related to total quality management, including quality control (QC), quality assurance (QA), quality indicators, and quality improvement (QI). Together, they contribute to minimizing errors (pre-analytical, analytical, or post-analytical) in clinical service delivery and improving process appropriateness and efficiency. In contrast to static quality benchmarks (QC, QA, quality indicators), the QI paradigm is a continuous approach to systemic process improvement for optimizing patient safety, timeliness, effectiveness, and efficiency. Healthcare institutions have placed emphasis on applying the QI framework to identify and improve healthcare delivery. Despite QI's increasing importance, there is a lack of guidance on preparing, executing, and sustaining QI initiatives in the field of laboratory medicine. This has presented a significant barrier for clinical laboratorians to participate in and lead QI initiatives. This three-part primer series will bridge this knowledge gap by providing a guide for clinical laboratories to implement a QI project that issuccessful and sustainable. In the first article, we introduce the steps needed to prepare a QI project with focus on relevant methodology and tools related to problem identification, stakeholder engagement, root cause analysis (e.g., fishbone diagrams, Pareto charts and process mapping), and SMART aim establishment. Throughout, we describe a clinical vignette of a real QI project completed at our institution focused on serum protein electrophoresis (SPEP) utilization. This primer series is the first of its kind in laboratory medicine and will serve as a useful resource for future engagement of clinical laboratory leaders in QI initiatives.

A randomized double-blind comparison of a morphine-fentanyl combination vs. morphine alone for patient-controlled analgesia following bowel surgery.

An ideal patient-controlled analgesia (PCA) opioid would have both a rapid onset and a long duration of action, attributes, which are not available in currently existing opioids including morphine, the most widely used agent. A mixture of rapid onset and long-acting opioids may potentially achieve both these qualities. In a randomized, double-blind study, we compared a fentanyl-morphine combination with morphine alone for PCA, in 54 patients undergoing bowel surgery. The combination solution was prepared according to a 1:75 fentanyl to morphine potency ratio. The mixture contained fentanyl 13.33 mug/mL and morphine 1 mg/mL. The morphine alone solution contained 2 mg/mL. Patients were randomly allocated to one of the regimens and were then evaluated 4 times during the first 48 hours following surgery. Time to effect, visual analog pain scores, opioid consumption, demands, deliveries, and side effects on an opioid-related symptom distress scale were recorded. Groups were well matched for age, weight, and sex. There were no significant differences between groups in time to effect, PCA usage, pain scores or side effects other than the occurrence of nausea, which was lower for the combination group in 1 visit. Further studies are needed to explore the potential of different potency ratios and opioid combinations to achieve rapid and long-lasting pain control.