Improving the Accuracy of Dermatology Specimen Labeling

Susan Y. Chon, M.D.Susan Y. Chon, M.D.Assistant ProfessorAssistant ProfessorDepartment of DermatologyDepartment of DermatologyUT MD Anderson Cancer CenterUT MD Anderson Cancer Center

Overview of the problemOverview of the problem

Dermatology specimens are being processed with errors in the Melanoma and Skin Center Clinics

Wrong patient name Wrong site Wrong side Missing label Missing pathology form

Background DataBackground Data

Dermatology samples are collected and Dermatology samples are collected and transported in small specimen bottles labeled transported in small specimen bottles labeled with the following:with the following: Patient NamePatient Name Specimen source site (body part, left/right)Specimen source site (body part, left/right) Date takenDate taken

A pathology form accompanies the specimen A pathology form accompanies the specimen to the pathology labto the pathology lab

Background DataBackground Data

A mistake (defect) in any of the above A mistake (defect) in any of the above information results in, at a minimum rework information results in, at a minimum rework (corrections and addendums to pathology (corrections and addendums to pathology reports), and can possibly result in diagnosis reports), and can possibly result in diagnosis or treatment errors. or treatment errors.

During a two week period in the month of During a two week period in the month of February, 13 mislabeled specimens were February, 13 mislabeled specimens were caught at the Clinic level.caught at the Clinic level.

Aim Statement

Reduce the number of mislabeled specimens Reduce the number of mislabeled specimens

from the Department of Dermatology, from the Department of Dermatology,

Melanoma and Skin Center clinics, Melanoma and Skin Center clinics,

delivered to the Department of Pathology by delivered to the Department of Pathology by

50% by 4Q, 201050% by 4Q, 2010

How Will We Know That a Change is an Improvement?

A defect is defined as: Any dermatology sample whose label or pathology

report has been corrected for site, name, etc.

This will be measured by count of defects

Our goal is to reduce defects by 50%

Total Total specimens specimens

20092009

11 GastrointestinalGastrointestinal 18,14418,144

22 GenitourinaryGenitourinary 14,62014,620

33 SkinSkin 14,52914,529

44 BreastBreast 11,67611,676

55 Head and NeckHead and Neck 99559955

66 GynecologyGynecology 56655665

77 ThoracicThoracic 48854885

88 Soft tissueSoft tissue 19611961

99 NeuroNeuro 18791879

1010 BoneBone 15431543

1111 HemepathHemepath 14801480

1212 CytologyCytology 228228

1313 UnassignedUnassigned 137137

TotalTotal 86,70286,702

Process AnalysisData Gathering Process Mapping

Data was gathered for several weeks, which included:

1. MRN2. Labeling Defects3. Provider4. Information re: discovery

The process was observed by multiple people, mapped and refined by the team. Significant variation in the process was observed.

Cause and Effect Analysis

The team used a fishbone diagram to narrow down the suspect causes the actual labels (including handwriting) and the time when the labels are written and entered in the database.

Baseline Data – Defect Types

“No site written” was the primary defect type, followed by “Wrong patient name” and “Illegible handwriting. ”

Total defects at Baseline Baseline surveillance for two weeks between February 15- February 26,2010

Total errors = 13/172

Error rate = 7.6%

Benchmarking - CPB

A different process was discovered in use in CPB. This process appeared to meet the needs of both departments, and was successful in reducing defects through use of preliminary work and careful double-check.

Interventions (Plan) Based on our observations and upon benchmarking Based on our observations and upon benchmarking

CPB, the following interventions were planned:CPB, the following interventions were planned: Labels and forms printed Labels and forms printed priorprior to entering the to entering the

patient’s roompatient’s room Labels and forms taken into patient’s room and Labels and forms taken into patient’s room and

specimen containers labeled specimen containers labeled priorprior to taking specimen to taking specimen Standardized method and abbreviations on the Standardized method and abbreviations on the

specimen labelsspecimen labels Active double check as the specimen is placed in the Active double check as the specimen is placed in the

bottle by physician and MA/RNbottle by physician and MA/RN

Proposed Modified Flow (Intervention)

The new flow is based on the benchmark, modified as appropriate for use in the main clinic.

Pilot & Process Audit

Modified flow was in pilot phase during October (10/25-10/29) in the Melanoma and Skin Center Clinics

Analysis of the process results showed No defects ( 0/68) Error rate 0% No increase in time or difficulty in adapting to the new

process

No further process refinements were found

Full-scale Implementation

Current plan is to monitor implementation to all clinics in the Melanoma and Skin Center

Standard procedures, policies and training plans will be put in place as a method of sustainment

Return on investment:Benefits to ensuring no mislabels Avoid errors that could severely impact

patient care

Save physician and staff time 1 hour to correct a pathology specimen.

Dermatology and dermatopathology departments spend time hunting down the error.

Avoid costly litigation to MD Anderson Cancer Center

Summary Recognized a problem with labeling of

dermatology specimens

Identified critical step in process

Implemented and studied pilot with new process

Next step: maintaining implementation to all Melanoma and Skin Center Clinics

Continue to collect data by monitoring and sustaining the process in clinic

The TeamThe Team Team MembersTeam Members

Victor Prieto, MD, Professor, PathologyVictor Prieto, MD, Professor, Pathology Susan Y. Chon, M.D., Assistant Professor, Department Susan Y. Chon, M.D., Assistant Professor, Department

of Dermatologyof Dermatology Lourdes Lujan, RN, OCN, Nurse Manager, Melanoma Lourdes Lujan, RN, OCN, Nurse Manager, Melanoma

and Skin Center and Skin Center Alyson Knight, MHA, Hospital Administrative FellowAlyson Knight, MHA, Hospital Administrative Fellow Marshall Nauck, MEE, AD, Quality Engineering Marshall Nauck, MEE, AD, Quality Engineering