[1881] The Effect of Process Variability on Frozen Section Latent and Active Error, Turn around Time, and Efficiency

SB Sams, ML Smith, TA Wilkerson, AE King, SS Raab. University of Colorado Denver, Aurora, CO

Background: The quality metrics of an intraoperative consultation with frozen section examination include diagnostic accuracy and turn around time. The effect of process variability on these metrics, efficiency, and risk of error has not been studied.
Design: Using Lean methods, we performed process mapping of 35 intraoperative frozen section consultations in an academic institution where specimens are accessioned by technicians, examined grossly and sectioned by residents, and interpreted and reported by attending pathologists. We broke down the entire process into 10 main steps and by using observational techniques, we measured the frequency of latent and active errors and variability of turn around time of each step. Using time motion analysis, we measured the excess work, or inefficiency of each step. For each error, we performed root cause analysis using Lean and Eindhoven methods.
Results: In all cases, there was no major or minor diagnostic discrepancy, although the number of latent and active errors averaged more than 10 per case. Active errors included failure to page residents and pathologists, using inappropriate techniques of sectioning and staining, coverslipping wrong slides, failure to prepare cryostats, failure of pathologists to be present when cases were ready for sign-out, and lack of diagnostic or technical back-up. Using Eindhoven methods, latent errors included the lack of paging and response protocols, the lack of training in gross examination and sectioning techniques, and the lack of focus on safety practices. In no case did the residents perform the individual specimen sectioning steps in the same manner. The mean turn around time between receipt and diagnostic call was 22:04 minutes, although individual steps ranged in completion time by more than 50%. The most variable steps in terms of turn around time were block preparation, sectioning, and pathologist sign-out. Overall, there was 35% excess waste in motions and unnecessary work for each case (range 15%-70%).
Conclusions: We conclude that our frozen section service showed marked lack of standardization of all process steps. This lack was not correlated with major diagnostic errors in our small sample size, but our processes were associated with a high frequency of latent and active errors that may contribute to major errors in rare cases. We also found that the lack of standardization contributed to delayed case turn around times and considerable inefficiency in work effort.
Category: Quality Assurance

Monday, March 22, 2010 9:30 AM

Poster Session I Stowell-Orbison/Surgical Pathology/Autopsy Awards Poster Session # 249, Monday Morning


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