Enhancing Patient Safety through Multi-Departmental Perioperative Surgical Specimen
Rita D'Angelo, Nelson Main, Richard J Zarbo. Henry Ford Hospital, Detroit, MI
Background: Perioperative specimen safety is a focus of proposed standardized processes defined by the World Health Organization Guidelines for Safe Surgery and Association of Operating Room Nurses. Patient identification the #1 national patient safety goal and is addressed by Pathology accrediting bodies. The Michigan Hospital Association Keystone Surgery Initiative is a statewide collaborative of 85 hospitals focused on benchmarking and sharing best practices to increase perioperative patient and specimen safety and quality.
Design: This is the experience of multi-disciplinary teams from Pathology and Surgical Services at Henry Ford Hospital, Detroit in solving specimen safety issues as participants in the statewide collaborative. Using a data-driven PDCA approach to testing interventions through the Henry Ford Production System LEAN quality initiative, we assessed measures of defective labeling and handling of specimens, requisitions, containers over 18 months with a standardized data input tool. We captured failures to provide required information elements on each specimen requisition and container received by Pathology from main hospital operating rooms. Numerous sources of defects of specimen labeling and handling were then targeted by interventions and the effect measured.
Results: Data collection period: January 2010 through September 2011
Interventions tested: 1) regular customer-supplier meetings between OR and Pathology, 2) specimen handling training video for OR surgical services staff, 3) education of surgeons on WHO perioperative read-backs, 4) targeted daily pathology interventions, 5) OR TV to educate surgeons at scrub-in, 5) specimen labeling stations in each OR to standardize handling and labeling pathways for specific specimen streams to include routine, frozen scetion, lymphoma, lung and microbiology tissue samples.
Daily defect data collected:
Surgical requisitions (average 700/month)- January 2010- 7 defects, September 2011- 3 defects
Containers (average 1400/month)- January 2010-15 defects, September 2010- 0 defects
Specimens (average 670/month) January 2010- 19 defects, September 2010-3 defects
Interventions resulted in an overall 84% reduction in specimen defects.
Conclusions: The success in targeting specimen safety is attributed to the team approach to standardizing the numerous specimen hand-offs. The data-driven PDCA approach to monitoring defects and changes is effective in driving and sustaining interventions to ensure that processes are maintained and followed. This also requires ongoing education and support of all in an effort to achieve a zero defect goal.
Category: Quality Assurance
Monday, March 19, 2012 1:45 PM
Platform Session: Section G, Monday Afternoon