[2090] An Audit of Dermatopathology Requisitions: Hand Written vs Electronic Medical Record Data Entry Accuracy

Christopher L Kinonen, William G Watkin, Briana C Gleason, Charnell EJ Johnson, Antoinette B Thomas, Thomas L Cibull. NorthShore University HealthSystem, Evanston, IL; Diagnostic Pathology Medical Group, Sacramento, CA

Background: At NorthShore University HealthSystem, dermatopathology (DP) case requisitions are received in hand written form or via electronic medical record (EMR). There are multiple categories for requisition data entry including patient demographics, physician name, and procedure site/date. Data entry error propagates inaccurate patient information and potentially delays billing/revenue collection. The DP service maintains a high case volume and thus systematic data entry problems potentially cause considerable documentation error. We reviewed DP data entry errors on hand written requisition forms compared to data entry errors via EMR.
Design: 11,475 DP requisitions (8,545 hand written, 2,930 EMR) were included in the study (4/1/2011-9/30/2011). Data entry errors were documented and categorized as cases were accessioned and reviewed.
Results: Results are illustrated in table 1.

Category of error	# of hand written requisition errors	# of EMR requisition errors	Total # of errors
Mismatch between existing computer demographics/hand requisition	37	NA	37
Illegible requisition/container label	3	0	3
Requisition with incomplete/absent demographics	3	0	3
Requisition with no physician indicated	1	0	1
Requisition with wrong collection date	1	2	3
Specimen container not labeled	2	1	3
Specimen container with no patient name	10	0	10
Mismatch between patient name on requisition form/container	8	0	8
Specimen container with no procedure site	152	95	247
Mismatch between procedure site on requisition form/container	35	13	48
Wrong patient accessioned	4	0	4
Other	2	2	4
Total Errors	258	113	371
Total requisitions	8545	2930	11475
Overall error rate	3.0%	3.9%	3.2%

The majority of errors occurred with container labelling. More specifically, procedure site was either not on the container or there was a discrepancy between the site indicated on the container and on the requisition. Container labelling is currently a hand written process. The EMR does not generate labels and 109/113 EMR errors (96%) were related to container labelling.
Conclusions: 1.With both hand written and EMR requisitions, the most common source of error is specimen container labelling.
2.Currently, even with EMR, containers are hand labeled and 96% of EMR errors occurred during this process. Other EMR data entry errors are extremely uncommon (4/2930 cases). This suggests introduction of a labelling process linked to EMR data entry could nearly eliminate data entry errors.
3. Although this study focused on DP cases, the findings can be applied to all types of specimens.
Category: Quality Assurance

Monday, March 19, 2012 9:30 AM

Poster Session I Stowell-Orbison/Surgical Pathology/Autopsy Awards Poster Session # 308, Monday Morning