[2032] Impact of Streamlined Adverse Event Entry

Luke T Wiehagen, Susan M Kelly, Geoffrey H Murdoch, Anthony L Piccoli, Samuel A Yousem, Liron Pantanowitz, Anil V Parwani, Raja R Seethala. UPMC Presbyterian Shadyside, Pittsburgh, PA

Background: Entry of Adverse Events (AE) is the primary mechanism for the recording of in process “defects” in Anatomic Pathology. Ideally, this should be a rapid, easy process in order to maximize participation and thus provide a more accurate assessment of the prevalence of process defects. Through software enhancements and structured revisions to the lengthy and tedious AE and resolution dictionaries in the laboratory information system (LIS), our aim was to increase the participation of pathologists and technical staff to assist in quality improvement and patient safety.
Design: Modifications were made in our LIS (CopathPlus) to eighty one windows and tabs to enhance and streamline reporting. A new dictionary was designed which centered around workflow and phases of testing resulted in 8 main categories (assigned alphanumeric codes for quick retrieval). Branching subcategories of the most critical events in each category were created and a free text field was expanded to allow for a detailed description of the event. Each main category was painted on the top of the AE window in CoPathPlus for reference. Once a main AE category was selected a pop-up window displayed only the associated subcategories for easy selection. A comparison between the AE entry rates per month was performed pre and post implementation.
Results: There was an overall reduction from 254 dictionary terms to 63 terms. With the branching subcategory display, the effective number of terms that the end user has to sort through decreased from 254 to between 8 and 14 options. AE entry rates were measured pre and post implementation and illustrated in Table 1. The comparison of the two time periods showed a very dramatic increase of the recording of “defects” post implementation. Overall, there was a 124.4% increase when the two time periods were compared.

Table 1.
MonthUsage PRE ImplementationUsage POST ImplementationPercent Change

Conclusions: A structured, workflow-based dictionary resulted in a large and sustained increase in AE reporting. This overall process improvement can potentially enhance the recognition of defects that may impact patient safety and error reduction in the pathology laboratory.
Category: Quality Assurance

Tuesday, March 5, 2013 9:30 AM

Poster Session III # 260, Tuesday Morning


Close Window