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 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.
The know error® specimen security system
is one way to ensure that errors, such as the switching of patient
biopsies, undetected by quality assurance systems already in place do
not remain undetected. Like the system at Henry Ford, the know error® system also employs a bar-coding system for the purpose of reducing errors; however, it is the DNA confirmation that prevents errors from resulting in an adverse patient outcome. The know error® system
confirms a positive biopsy result by sending tissue from the biopsy and
a separate tissue sample taken from the patient via a cheek swab to an
independent forensics lab. The lab then matches the biopsy tissue
sample with the reference sample from the patient. A match confirms
the cancerous tissue sample belongs to the patient. If there is not a
match, the process is halted prior to any surgery or cancer treatment
taking place.
For more information about the know error® specimen security system with unique patient code and DNA confirmation, please visit our web site at www.knowerror.com.
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