Improving Patient Safety: Instituting Mandatory "Pathology Specimen Time-Out" in the Operating Room as a Means for Reducing Patient/Specimen Identification Errors
Melanie J Kubik, Bruce Villas, Amir Mohammadi, Sania Shuja. University of Florida College of Medicine, Jacksonville, FL
Background: The national drive towards establishing a comprehensive Electronic Medical Record (EMR) underscores the importance of accuracy of such records. ACGME specifically requires training programs to educate residents in identification and prevention of human/system errors and implementation of solutions, as components of practice-based learning and improvement, and systems-based practice. Our previous study of root cause analysis of surgical pathology reports released on the wrong patients revealed that incorrect entry of patient or specimen information occurred most frequently in the operating room (OR), due to high volume of specimens received from the OR. The objective of our current study is to prevent errors through implementation of mandatory “pathology specimen time-out” (PSTO) in our institution's OR policy. Here we report results of our performance improvement measure for reducing patient/specimen misidentification by the OR.
Design: We implemented mandatory PSTO in our OR policy in June 2010. PSTO was defined as “patient re-identification and re-confirmation of specimen site and laterality” at the time of acquisition of the specimen in the OR. Subsequently, all amended surgical pathology reports released on wrong patients from July 2010 through August 2011 were reviewed. In addition, we reviewed all “near-misses” from OR, defined as “improper or incorrect patient and/or specimen identification recognized by pathology staff before completion and release of report,” thus preventing patient or specimen misidentification and avoiding an amended report.
Results: Before institution of the mandatory PSTO, 16 reports were released on wrong patients out of a total of 50,000 surgical pathology reports from January 2006 to June 2010 at our institution. In the subsequent 13 months following institution of mandatory PSTO, 4 reports were released on wrong patients out of a total of 14,000 surgical pathology reports, and none of these amended reports occurred due to OR entry error. All 4 amended reports were a result of entry error at clinics where mandatory PSTO had not been implemented. In addition, there was a progressive decline in “near misses” from the OR during this 13 month period.
Conclusions: Mandatory PSTO implementation in the operating room is an effective preventive mechanism for reducing patient/specimen entry errors into EMR, thus contributing to patient safety and should be adopted as a national/global standard of care.
Category: Quality Assurance
Monday, March 19, 2012 1:00 PM
Poster Session II # 252, Monday Afternoon