Improving Transfer of Patient Care Information Between OBGYNs and Pathology Department [23E

Abstract

INTRODUCTION: The greatest number of medical errors occurs at the time of transfer of patient information. This performance improvement project seeks to improve patient safety by improving the communication between obstetricians/gynecologists and pathologists at single tertiary care facility. Ensuring no errors in the surgical pathology forms ensures that patients receive appropriate and timely pathologic evaluation. METHODS: A multidisciplinary team of clinicians and leaders from multiple departments developed educational materials for physician and staff handling pathological specimens, provided individual and group feedback and optimized pathology forms to decrease the amount of errors in communication as pathologic specimens change hands. The number of pathology form errors was identified at the end of every quarter from 2014 to 2016 at Kaiser Permanente Santa Clara. RESULTS: Prior to implementation of this project 11 errors were found in a single quarter. Following the implementation of this project, there was a 68% decrease in yearly pathology form errors. This included a steadily quarterly decline that contained 4 quarters without any errors. There was one outlier in the first quarter of 2015 which contained 6 errors. CONCLUSION: This project demonstrates that communication between different departments, educational training, directed feedback and optimization of pathology forms can decrease the amount of errors in transfer of patient care information, leading to improved patient care and safety.