[1660] Root Cause Analysis of Surgical Pathology Identification and Information Defects

SS Raab, AM King, DM Grzybicki. University of Colorado Denver, Aurora, CO

Background: Anatomic pathology identification defects may lead to catastrophic patient outcomes. The best known examples are those associated with the switch of one patient specimen with another. More commonly, these defects are secondary to incorrect or incomplete patient information. We determined the frequency, root causes, and effect on laboratories of identification/information defects.
Design: We used a direct observational method to determine the frequency of surgical pathology and cytopathology identification and information defects. By observing the accessioning process, a trained individual recorded the presence of accurate information for 8 fields on the specimen containers and 10 fields on the requisition forms (e.g., patient name, second patient identifier, date of collection) over a two week period of time (570 surgical pathology and 76 non-gynecologic cytopathology specimens). We determined the frequency of specific field defect and performed root cause analysis to determine the causes of specific defect types occurring at individual pre-analytic specimen procurement sites (n=33). During the observational process, we determined accessioner responses to specific field defects and the time in performing work-around activities.
Results: No specimen (container and requisition) was defect free, although the frequency of defect varied considerably by container (e.g., 1.7% lacked an accurate patient name or second identifier, 3.4% lacked a date of collection, 7.3% lacked a physician name, and 99% did not report the location of specimen procurement) and requisition (e.g., 1.6% lacked a specimen description and 15% lacked clinical history). The frequency of specific defect types varied considerably by pre-analytic collection site (e.g., patient name defects occurred only in some clinics). Root cause analysis showed that the overwhelming majority of these defects occurred as a result of the lack of standardized pre-analytic processes and lack of redundant checks. Accessioners spent considerable time (15 minutes to 45 minutes) in fixing specific individual defects, ignored the lack of information in most cases, and made assumptions to correct information other defects.
Conclusions: Specimen identification and information defects occur at a high frequency and are secondary to the lack of pre-analytic protocols and processes. These defects generally result in laboratory workers spending considerable time in performing work-arounds and making potentially risk-associated assumptions.
Category: Quality Assurance

Monday, March 9, 2009 1:00 PM

Poster Session II # 242, Monday Afternoon