Eliminating Pathology Specimen Handling and Labeling Errors/Deficiencies

Carle Foundation Hospital and Carle Clinic Association
Urbana, Illinois, USA

Team

Allen Rinehart, RN, BSN – Manager, Emergency Department (CFH)
Ann Vannice, RN, MS – RN Educator, Clinic Educational Services (CCA) 
Becky Duncan, RN, CNOR - Manager, Operating Room (CFH)
Beth Hellmer, MS, MT(ASCP) – Director of Operations, Laboratory and Pathology Services (CCA)
Carla Kurtz, RN, MS – Director of Surgical Services (CCA) 
Carol Bueker, RN, BSN  - Mattoon Branch Clinic (CCA)
Charles Embrey, PA(AAPA) – Manager, Histology (CCA) 
Cindy Ziegler, RN - Champaign Branch Clinic (CCA)
Coletta Ackermann, BSN, MEd – Director, Corporate Education (CFH)
Frank Bellafiore, MD - Pathology (CCA)
James Gregory, MD, FACS –Head, Dept of Surgery (CFH); Medical Director Surgical Services (CCA)
Jean Mills, RN, MS, BC – Lead Educator, Hospital Education (CFH)
Jim Roberts, RN - Patient Safety Coordinator, Foundation Quality (CFH)
Joan Plunk, RN, BSN - Manager, Special Procedures (CFH)
Julianna S. Sellett, RN, MBA - Performance Improvement Facilitator, Foundation Quality (CFH)
Julie Root, RN - Director, Surgicenters (CFH)
Karen Perry – PCA, Dermatology (CCA)
Karon L.Hammel - Manager, Obstetrics/Gynecology  (CCA)
Kathy Browning, RN, BSN – Staff nurse, Oral Surgery (CCA)
Letha S. Kramer - Risk Manager (CFH/CCA)
Lisa Rogers – Patient Care Coordinator, ENT (CCA)
Lora Lang, LPN/GI Technician - Special Procedures (CFH)
Lori Wilson – PCA/Lab, Rantoul Branch Clinic (CCA)
Mindy Spencer -  Patient Care Manager, SC2 Family Medicine (CCA)
Monica Ray, RN, BSN – Manager, Foundation Quality (CFH)
Monique Mann – MOA, Obstetrics/Gynecology (CCA)
Napoleon Knight, MD – Vice-President of Medical Affairs (CFH)
Pam Schwartz, RN, BSN - Coordinator, SC2 Family Medicine (CCA)
Pamela Lewis - RN Coordinator, OB-Gyn (CCA)
Ramona Cheek, RN, MS, CPHQ – VP of Patient Care and Quality (CFH)
Shawn Russell, R.T.(R) RDMS – Staff Sonographer, Radiology (CCA)
Sheila Calandro, RNC, MS – Director of Education and Development (CCA)
Sue Reardon, MS, MT(ASCP)SBB – Patient Care Director (CCA)
Susan Olthoff, RN – Oral Surgery (CCA)
Troy Rhodes, RN, BSN – Operating Room (CFH)

 

Additional Support Provided by:

CCA Leadership
CFH Leadership
Information Technology (CCA)
Foundation Quality (CFH)

 

Aim

To reduce pathology specimen handling and/or labeling errors/deficiencies to zero.

 

Measures

  • Monthly percentage of pathology specimen handling and/or labeling errors/deficiencies
  • Monthly severity of pathology specimen handling and/or labeling errors/deficiencies


Changes

Obtained baseline data on pathology specimen handling and/or labeling errors/deficiencies that had occurred in the system; data yielded valuable information on actual scope of problem. Assembled an interdisciplinary team and conducted a Failure Mode and Effects Analysis; all known and potential system failures were addressed and/or acted upon.

 

Began tracking 100 percent of errors/deficiencies; gave ability to monitor progress of initiatives.  Errors/deficiencies tracked weekly, monthly, and quarterly; as well as, by proceduralist, location, type and severity.

  • Standardized and revised pathology specimen handling and labeling process for all CFH and CCA locations. Policy and procedure located on organization’s intranet site; complete with examples on how to fill out related forms, labels, etc.
  • Created policy that standardizes actions to be taken by Histology when specimen arrives with errors/deficiencies.
  • Required proceduralist to verify correct specimen(s) is/are in the correct container(s) and information on label and requisition are complete and correct prior to leaving procedure area. Second person to double-check all of the information. Specimens cannot be sent without these verifications.  
  • Created a standard label to be used for all pathology specimens.
  • Eliminated smallest sized specimen containers from stock; reduced chances of inappropriate tissue: formulin ratios from occurring.
  • Developed container reordering forms with pictures; reduced chances of staff ordering inappropriate sizes of containers.
  • Ensured container par levels were established; reduced chances of depleting stocks of appropriate sized containers.
  • Developed specimen tracking systems; CFH via computer order entry and CCA via logging system.
  • Installed label printers in locations without them; printers with barcode capability for future initiatives.
  • Modified and standardized computer order entry screens for CFH and requisitions used by CCA.
  • Created “quick reference” wall charts/posters for procedure areas.
  • Standardized vendors for containers; chose containers with the lowest known defects.
  • Created secure holding areas for specimens while waiting for transport.
  • Standardized guidelines for specimen transport.
  • Made education on process a requirement for physicians, residents, physician assistants, advanced practice nurses, nurses, technicians, procedure assistants, and any other staff involved in the handling and/or labeling process.
  • Provided global feedback to staff on errors until initiative went live. From that point on, direct feedback given to attributing parties and their leadership.
  • Began monthly reporting to the CFH Board and quarterly reporting to other CFH and CCA leadership.
  • Classified severe errors/deficiencies as Sentinel Event; to be worked-up accordingly.
  • Developed leadership expectations for follow-up; added closure to feedback process.
  • Incorporated competencies into orientation programs for new staff.
  • Developed yearly competencies for current staff.

 

Results
Graph_monthlypercentageofpathologyspecimenhandlingand_orlabelingerrors_deficiencies.jpg 

 

Summary of Results / Lessons Learned / Next Steps

 
Summary:
As system-wide educational efforts continue and direct feedback is provided to attributing parties, CFH and CCA have had a sustained, downward trend in the percentage of pathology specimen handling and labeling errors/deficiencies.  
 
Lessons Learned:
  • Recognize that laboratories cannot correct specimen handling and labeling errors/deficiencies alone; improvement efforts must be shared with healthcare system leadership in order to effectively address errors/deficiencies generated by non-laboratory staff.
  • Remember that system changes do not have to be high-cost to be effective.  
  • Establish multidisciplinary teams composed of system-wide representation of those involved in the handling and labeling process, as well as, representation from leadership, laboratory, risk management, information technology, and education. Let each member be involved in his/her areas of expertise/interest; increases participation and compliance.
  • Do not rule out having a large Performance Improvement team (contrary to what the books say) when addressing a large, multi location, interdisciplinary system failure; may be necessary to adequately address unique issues existing in each location. A large team can be broken down into smaller teams to address various parts of a process.
  • Allow staff to participate on these teams no matter how “busy” or short-staffed you may be; patient safety is at risk and will continue to be unless system errors/deficiencies are addressed.
  • Obtain administrative and medical staff support and address their issues and concerns prior to developing process; increases success of initiatives. 
  • Include ancillary departments (i.e. education and information technology) in early phases of development; will facilitate a smoother implementation. 
  • Generate system awareness of errors and provide rationale for change. Include actual examples of how errors/deficiencies have impacted patients, families, and the organization (including risk management and financial impact); adds a realistic perspective and encourages acceptance of change. 
  • Have overall specimen error/deficiency tracking and associated reporting performed by a neutral department, such as quality/patient safety; maintains integrity of relationships between the laboratory and other departments. 
  • Provide direct feedback to the attributing individuals whenever an error/deficiency occurs. Most individuals are not aware they have had an error/deficiency. Feedback reduces future probability of reoccurrence.
  • Provide routine feedback to leadership; brings awareness of what is happening within their departments and allows second opportunity for feedback.
  • Require all individuals involved in the handling and/or labeling process to attend an educational session if a system-wide interdisciplinary failure has been identified. Be flexible and creative with education times and opportunities; there is no such thing as downtime.
  • Develop standardized presentations and educational packets; ensures individuals are receiving the “same message.”
  • Expect some resistance to change and recognize this will decrease over time.
  • Build education into orientation programs for new staff and yearly competencies for existing staff.
  • Share your successes and failures with other healthcare organizations outside of your system; methods to optimize patient safety should not be kept a secret.
 

Contact Information
Julianna S. Sellett, RN, MBA – Performance Improvement Facilitator
Carle Foundation Hospital
Foundation Quality, South Clinic – 6
Julianna.Sellett@Carle.com
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