Labeling Errors in a Surgical Pathology Gross Room: A Root Cause Analysis
Robert L Schmidt, Bonnie Messinger, Lester J Layfield. University of Utah School of Medicine, Salt Lake City, UT; ARUP Laboratories, Salt Lake City, UT
Background: Medical errors can occur in the pre-analytic, analytic and post-analytic phases of specimen evaluation. Mislabeling of specimens is an infrequent but significant cause for diagnostic error. Specimen labeling errors may occur before receipt in the Surgical Pathology laboratory, during the grossing process, slide preparation and report dictation. Specimen accessioning and “grossing-in” appear to be sites where a significant number of mislabeling errors occur. Root cause analysis of gross room errors could lead to an understanding of causes for mislabeling and a reduction in mislabeling and associated errors.
Design: The Quality Assurance records of ARUP Laboratories were reviewed for all labeling errors between July 2009 and April 2011. Root cause analysis was undertaken to identify circumstances (what, who, when, where) of the error. Analysis of error descriptions included the point in the process where the error occurred, error impact (within case vs between case), and error type (e.g., transposition of numbers, “one-off” shift in digits). Logistic regression was used to explore associations between errors and causal factors such as daily case load, time of day, day of week, case complexity and employee category. Quality analysis tools such as a process flow diagram, a control chart, cause and effect diagrams and “five-why” analysis were used to explore causal relationships.
Results: 85 labeling errors were identified in 42,684 specimens processed during the study period. The error rate was stable over this period and was almost 10 times higher for residents than for regular staff (p<0.001). The error rate varied by specimen type being lowest for dermatology specimens (p< 0.001). Among non-dermatology specimens, the error rate was significantly higher for complex specimens (p<0.001). Errors were unassociated with daily case load, day of week or time of day; there was a significant increase in errors at the end of the day on Friday and Saturday. Errors were evenly divided between within-case and between case errors. Root cause analysis identified work space crowding, cassette printer design and cassette handling mechanisms as possible contributors to error.
Conclusions: Labeling errors are associated with specific factors (employee type, specimen type and particular time periods). Improved supervision of house staff and error prone processes may reduce labeling errors. Increased oversight of labeling of complex specimens and specimens processed during particular times of days may improve specimen labeling.
Category: Quality Assurance
Monday, March 19, 2012 1:00 PM
Poster Session II # 248, Monday Afternoon