A Resident-Driven Process Improvement Project Decreases Cassette Labeling Errors
Anne Hiniker, Kristie White, Carrie Oto, Timothy Morken, Luke Perkocha. UCSF, San Francisco, CA
Background: In healthcare, there is increased recognition of the value of process improvement to increase efficiency and improve patient safety. An important challenge for Anatomic Pathology (AP) laboratories is to adopt these techniques and to provide education and experience in this discipline to residents. AP residents identified this need in the context of specimen cassette labeling in the gross room. We used process improvement techniques to identify and resolve both systematic and individual sources of cassette labeling errors, resulting in a measurable and sustained decrease in errors at our institution.
Design: “Errors” were defined as any labeling deficiency that required correction, thus creating non-value-adding labor. These included incorrectly numbered or color-coded cassettes and discrepancies between the histology Laboratory Information System (LIS) worklist and the cassettes received in our off-site histology lab. Institutional data from 360,743 cassettes for 61,581 cases from academic years (AY) 2008-10 were analyzed. The average error rate for AYs 2008-09, 4.1%, was designated as the baseline error rate, with the goal to reduce this error rate by 25%.
A resident committee examined gross room cassette-labeling procedures to identify error-prone steps in specimen processing and transfer to the histology laboratory. Each step was analyzed for process inefficiencies and physical or technological limitations leading to error. “Best practices” were identified by observing the procedures of individuals with low baseline error rates, and used to institute systematic changes in process, procedure, and environment.
Results: The following interventions were made following analysis: replacement/relocation of cassette racks to improve ergonomics, maintenance of cassette labelers to reduce printing malfunctions, LIS programming and procedure changes to improve synchronization of cassette submission with histology worklists, and monthly data analysis with anonymous feedback of individual errors as compared to department averages. These changes reduced the error rate by 30% in AY 2010, and resulted in intangible changes in resident and PA awareness of the causes and impact of labeling error.
Conclusions: Over a 12 month period, this resident-driven project applied process improvement techniques to reduce the block labeling error rate by 30%, improving both laboratory efficiency and patient safety. An additional benefit was the development of a culture of continuous improvement, which resulted in increased housestaff enthusiasm and engagement in error reduction.
Category: Quality Assurance
Monday, March 19, 2012 1:00 PM
Poster Session II # 253, Monday Afternoon