1. Improving the Accuracy of Dermatology Specimen Labeling
My talk today will be discussing a project that involved the dermatology and pathology dept at MD Anderson.
Susan Y. Chon, M.D.
Assistant Professor
Department of Dermatology
UT MD Anderson Cancer Center 1

2. Overview 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
What was the problem?

3. Background Data
Dermatology samples are collected and transported in small specimen bottles labeled with the following:
Patient Name
Specimen source site (body part, left/right)
Date taken
A pathology form accompanies the specimen to the pathology lab
To give you some background on the problem.. 3

4. Background Data
A mistake (defect) in any of the above information results in, at a minimum rework (corrections and addendums to pathology reports), and can possibly result in diagnosis or treatment errors.
During a two week period in the month of February, 13 mislabeled specimens were caught at the Clinic level. 4

5. Aim Statement
Reduce the number of mislabeled specimens from the Department of Dermatology, Melanoma and Skin Center clinics, delivered to the Department of Pathology by 50% by 4Q, 2010 5

6. 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% 6

7. Total specimens 2009 1 Gastrointestinal 18,144 2 Genitourinary 14,6203
Skin
14,529 4
Breast
11,676 5
Head and Neck
9955 6
Gynecology
5665 7
Thoracic
4885 8
Soft tissue
1961 9
Neuro
1879 10
Bone
1543 11
Hemepath
1480 12
Cytology
228 13
Unassigned
137
Total
86,702
280 specimens/week

8. Process Analysis Data Gathering Process Mapping
The process was observed by multiple people, mapped and refined by the team. Significant variation in the process was observed.
Data was gathered for several weeks, which included:
MRN
Labeling Defects
Provider
Information re: discovery 8

11. 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.

12. Baseline Data – Defect Types
“No site written” was the primary defect type, followed by “Wrong patient name” and “Illegible handwriting. ” 12

13. Total defects at Baseline
Baseline surveillance for two weeks between February 15- February 26,2010
Total errors = 13/172
Error rate = % 13

14. 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.

16. Interventions (Plan)
Based on our observations and upon benchmarking CPB, the following interventions were planned:
Labels and forms printed prior to entering the patient’s room
Labels and forms taken into patient’s room and specimen containers labeled prior to taking specimen
Standardized method and abbreviations on the specimen labels
Active double check as the specimen is placed in the bottle by physician and MA/RN 16

17. Proposed Modified Flow (Intervention)
The new flow is based on the benchmark, modified as appropriate for use in the main clinic.

18. 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
Pilot (Do) & Process Audit (Study)

19. 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
Full-scale Implementation (Act)

20. 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
Accounts for about 15% of body wgt
Sub q is not part of the skin but considered in the discussion
Skin appendages/accessories: hair, sweat glands, nails

21. 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
Accounts for about 15% of body wgt
Sub q is not part of the skin but considered in the discussion
Skin appendages/accessories: hair, sweat glands, nails

22. The Team Team Members Victor Prieto, MD, Professor, Pathology
Susan Y. Chon, M.D., Assistant Professor, Department of Dermatology
Lourdes Lujan, RN, OCN, Nurse Manager, Melanoma and Skin Center
Alyson Knight, MHA, Hospital Administrative Fellow
Marshall Nauck, MEE, AD, Quality Engineering 22