Near-Miss Event Rates in a Traditional Surgical Pathology Accessioning and Gross Examination Laboratory
ML Smith, SS Raab. University of Colorado Denver, Aurora, CO
Background: The rate of near-miss event errors in the pathology gross examination laboratory has not been evaluated. Independent of the diagnostic abilities of the pathologist, errors in the laboratory may lead to catastrophic patient injury if not recognized and addressed. We hypothesize that the characterization of near-miss events in a traditionally designed surgical pathology laboratory will guide optimal re-design of work flow to minimize the potential for error.
Design: Via five days of direct observation of the laboratory process, we collected detailed data on the frequency of near-miss events during the receiving, accessioning, set-up and gross examination of specimens in an academic hospital which batches its work (annual volume: 22000 specimens). Near-miss events were those that if not caught and corrected may lead to a patient specimen being mixed-up with a different patient specimen. Events were categorized as process dependent (defined as near-miss events that occurred as a result of the work-flow process [e.g. cassettes from multiple patients are printed and dropped into the same container requiring technical staff to sort them out, specimens separated from requisition forms for accessioning, all biopsies set-up on one large tray]), and operator dependent (defined as near-miss events not associated with the work-flow [e.g. a patient specimen was inadvertently placed into another patient's cassette]). Twenty-four different operator dependent error categories were identified. Rates of events were calculated as: frequency of events divided by the number of specimens processed.
Results: 335 cases with 421 specimens were submitted to the laboratory for processing. The rate of operator dependent near-miss events was 0.6 events per specimen (more than one every other specimen). Operator dependent errors were sub-categorized into accessioning (6, e.g. wrong accession number written on requisition form), set-up (14, e.g. requisition paired with incorrect specimen container), and grossing (4, e.g. two different requisition forms in grossing area at the same time). 2310 process dependent near-miss events were identified, a rate of 5.5 events per specimen. The total near-miss event rate was 6.1 events per specimen.
Conclusions: Traditional batched work-flow design in the surgical pathology gross laboratory leads to an unacceptably high rate of process and operator dependent near-miss events. The dramatic number, identification, and categorization of near-miss events will aide substantially in the re-design of work-flow using lean methodologies.
Category: Quality Assurance
Tuesday, March 10, 2009 9:15 AM
Platform Session: Section F 1, Tuesday Morning