The January 2009 feature story of CAP TODAY, "Using Lean to End Labeling Errors," discussed the implementation of a bar-coding initiative at the surgical pathology lab at Henry Ford Health System. The program was considered a success after reducing labeling problems by 85%, according to Dr. Mark Tuthill, Director of Pathology Informatics.
The new "Lean" protocol involved bar-coding all patient-related materials - requisition form, tissue cassettes, specimen containers, and slides - all at the same time. Upon entering a patient into the system, the accessioner would print all of the bar codes for a particular patient. There were technological challenges with the bar-coding since linear bar codes couldn't be used. Tuthill partnered with General Data out of Cincinnati which had created a new cassette labeling system which could work in conjunction with the existing lab information system.
Further improvements were made once the bar-coding system was up and running to provide an additional set of checks and balances. The additional steps required the accessioner to: 1) Scan the requisition form using an optical scanner, 2) Re-key patient name, medical case number, and surgical path case number, and 3) Confirm a match between the requisition label generated by the computer (with bar code label) and the one provided by the clinician (without bar code label).
The story discloses: "If the clinician has put the wrong patient identifiers on the requisition form, there's no way to catch it." As discussed in an earlier blog post, "18 Steps Between Your Biopsy and Your Biopsy Result," evaluation of a biopsy tissue specimen is an extremely complex process. There are numerous steps and individuals involved. Even with safeguards such as these implemented at the Henry Ford Health System, there is still room for human error. While these improvements have reduced labeling problems by 85%, that itself is proof that errors still find their way through even the smallest cracks in the system.
Implementing a system to establish specimen provenance, such as the know error® system, is one way to ensure that complications, such as specimen transposition and patient misidentification, undetected by protocols already in place do not remain undetected. Like the system at Henry Ford, the know error® system also employs a bar-coding system; however, it is the addition of DNA Specimen Provenance Assignment (DSPA) that virtually eliminates the possibility that Specimen Provenance Complications (SPC) will result in an adverse patient outcome.
For more information about the know error® system, please visit our web site at www.knowerror.com.
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