Measures To Assure Tissue Identification during Intraoperative Consultation: A Patient Safety Measure That Prevents Tissue Mismatch
F Arif, J Melamed, D Warfield, BY Wang. New York University School of Medicine, New York, NY
Background: During intraoperative consultation (IOC), procedures for identification of tissue throughout the process are needed to prevent tissue mismatch. In a high volume frozen section service, where many cases are handled simultaneously, procedures and practical methods for labeling of the frozen block are key to secure correct identification. We have devised a few simple and easily implemented procedures to assure frozen tissue identification, and describe our four years experience with its implementation.
Design: We utilize several steps as part of our procedure to maintain identification of tissue throughout the IOC process. These include to 1) Embed and freeze a specimen with identification label directly into the block. 2) Limit wherever possible a single chuck per cryostat. 3) Require the cryostat operator to maintain custody of tissue and be responsible for transfer of tissue into a labeled cassette. We have monitored these procedures for ease of use and compliance by IOC personnel, and provide an estimate of the reduction of mismatch through implementation of this policy.
Results: In our institution these procedure have been readily accepted and implemented with 96% compliance rate (n= 8967 frozen section cases) over a 4 year period. On the few occasions, where the procedure was not followed, 3 “near miss” events were documented at a rate of 3 per 360 cases (0.8%) compared to 0 events in 8607 cases where the procedure was followed.
Conclusions: Adherence to simple practical procedures for tissue labeling during frozen section can be easily adapted to enhance patient safety, and can significantly reduce the possibility of mismatch.
Category: Quality Assurance
Monday, March 22, 2010 1:00 PM
Poster Session II # 206, Monday Afternoon