Improving Patient Safety: Root Cause Analysis of Surgical Pathology Reports Released on Wrong Patients.
Sania Shuja, Bruce Villas, Kevin Lee. University of Florida, College of Medicine-Jacksonville, Jacksonville
Background: The national drive towards establishing a comprehensive Electronic Medical Record System underscores the importance of accuracy of such records. The ACGME specifically requires training programs to educate residents concerning identification and prevention of human and system errors and implementation of solutions. We present Root Cause Analysis (RCA) for surgical pathology reports released in error on wrong patients at our institution during last 4 years. The objective of our analyses is to educate and provide feedback to all personnel participating in the health care system, and especially residents in-training.
Design: All amended surgical pathology reports that were released on wrong patients since 2006 were pulled and reviewed, as a component of Quality Assurance and Quality Improvement measure. For RCA, two patient identifiers were compared between correct patient and wrong patient. These included name (last and first) and date of birth (DOB) (month, day and year). Also, individual departments where incorrect electronic entries were generated were identified in each case.
Results: Of approximately 50,000 surgical pathology reports, 16 reports were released on wrong patients, error rate being approximately 1 in 3,000 reports. In 69% of cases (11 of 16 cases) correct and wrong patients had the same last names. Six of 11 patients had the same last and first names, however, the DOB were different in the correct and wrong patients. The remaining 5 of the above 11 cases with identical last names, had different first names. In 5 cases out of the total of 16 cases patients had different names and DOB (month or day in DOB was similar in two cases). Incorrect electronic entry originated in various departments, however, most of them occurred in the operating room (OR).
Conclusions: Our analysis indicates that the most frequent cause of incorrect entry into the electronic system was identical last names of correct and wrong patients (69% cases). Among this group, confirmation of first name reduced the error by 30%. In the remaining 39% of cases, the error could be avoided by confirming the DOB of the patient. Of last 31% (5 of 16 cases), erroneous entry was made in spite of different names and dates of births of the patients. The finding that incorrect entry most frequently occurred in the OR was due to the fact that most specimens were received from the OR. All errors could potentially be avoided by educating and emphasizing to the staff the importance of confirming two identifiers in each patient, during every electronic entry.
Category: Quality Assurance
Monday, February 28, 2011 1:00 PM
Poster Session II # 204, Monday Afternoon