Enhancing Peri-Operative Tissue Specimen Safety – Standardization of the Surgery-Pathology Hand-Off.
Rita D'Angelo, Richard Zarbo, Ruan Varney, Frank Torres, Osama Alassi, Gaurav Sharma, Oleksandr Kryvenko, Don Lubensky, Adrian Ormsby, Nelson Main, Sarah Richard. Henry Ford Health System, Detroit, MI
Background: Numerous bodies call for improving effectiveness of communication among caregivers (National Patient Safety Goal #2). A highly recommended process calls for verbal-written specimen identification with perioperative readback verification of verbal communication between caregivers (physician, scrub nurse, circulator) to prevent misinformation (WHO & AORN Guidelines for Safe Surgery). We describe our Lean based process changes to standardize the Surgery to Pathology hand-offs to improve specimen safety as part of the statewide Michigan Hospital Association's Keystone-Surgery initiative.
Design: Customer-Supplier teams trained in Lean process redesign were established between Surgical Services and Pathology at Henry Ford Hospital, Detroit, MI. to define mutual requirements, identify defects, lack of standardization, and brainstorm solutions to improve the quality of specimen hand-offs between caregivers. A daily database maintained by Pathology was created to longitudinally track specimen requisition and container defects related to specimen label, patient identification, numeric identifier, specimen source or type or laterality.
Results: Specimen defects were reduced by 90% in 2010 January (87) to July (8). The following process changes contributed: 1. A perioperative Read-Back was implemented from surgeon to circulator/scrub nurse to repeat information for each specimen as a standard communication. 2. A 15 minute specimen handoff training video was developed for Surgical Services personnel. Surgeon training consisted of a 30 second video of Read-Back instructions shown within the OR on OR-TV. 3. A chain of custody process was established with the Frozen Section room documenting receipt of specimens. 4. Specific specimen streams were created to standardize the approach to time sensitive (frozen section) or special handling cases. 5. Standardized label stations were created and placed within each OR for accurate specimen identification at the point of collection that provide color coded specimen container label stickers for each specimen stream. 6. Labels were further redesigned for frozen section indication to include a box for diagnosis and margin.
Conclusions: Marked improvement in specimen safety with effective and consistent communication of hand-offs can be achieved through engaged work teams focused on creating standardized work activities, connections, and pathways. The development and use of interim outcome metrics is key to guiding the adoption and understanding the impact of process improvement changes proposed to achieve the goal of zero defects.
Category: Quality Assurance
Monday, February 28, 2011 1:00 PM
Poster Session II # 206, Monday Afternoon