4:12 PMAbstract No. 324 - Application of plan-do-study-act (PDSA) principles to improve patient safety and specimen labeling errors in interventional radiology (IR)

Abstract

To improve patient safety through the reduction of specimen labeling errors in Interventional Radiology (IR). Baseline data collected by the pathology department included: number of labeling errors, types of errors (non-labeled, incompletely labeled, incorrectly labeled), and type of procedures associated with errors. These data were analyzed using a Pareto chart. Factors in IR contributing to these errors were analyzed through the development of process map, a fishbone diagram created by a multi-professional focus group (MD, RT, and RN), and a prioritization matrix. The PSDA methodology was employed with the goal to reduce specimen labeling errors. A statistical control chart was used to determine significance of these interventions to reduce specimen error rates. Baseline data demonstrated an overall specimen error rate of 4.2%, ranging from 16.7% to 0%. The Pareto chart showed that incomplete requisitions accounted for more than 80% of these errors. The process map demonstrated variation in ways referring providers requested specimens, how specimens were labeled, and who was responsible for specimen labeling. Using QI tools, the focus group developed 3 interventions: (1) creation of an order entry system which allows referring providers to choose which specific labs/specimens they want sent, (2) development of a standardized double-check process through which an RN or RT confirms the specimen labels with the operator at the end of the procedure, and (3) use of a label printer rather than hand-written labels for slides and specimen vials. Post-intervention showed a lower and more consistent error rate ranging from 2.1% to 0.2%, with an average error rate of 1.0%. Through the use of classic process improvement tools, we decreased the variability and overall frequency of specimen labeling errors in IR to 1%. Our next goal is to decrease our error rate to 0%, since these errors threaten patient safety and are entirely avoidable.