Hospitals have increasingly focused on optimizing procedures for patient safety, especially after the 1999 Institute of Medicine report "To Err is Human: Building a Safer Health System," which pointed out the financial and human consequences of errors.

In the clinical laboratory, patient safety issues are most commonly addressed by improving patient specimen identification. The Joint Commission has made requiring at least two forms of patient identification (which cannot include location or room number) a National Patient Safety Goal.

Our four acute care hospitals system has a single consolidated lab entity with a centralized core lab at one facility and rapid response labs at the others. Anatomic pathology functions such as cytology and histology are also centralized. Specimens are commonly sent from the rapid response labs to the core lab for esoteric or specialized testing or anatomic specimen processing.

In an overall hospital-wide project to improve patient safety, each of our lab sections was charged with developing a patient safety project. The following are descriptions of two of these, both with quantified results.

Tube Size Matters
The core hematology lab performs specialized coagulation testing, such as antithrombin III, protein C, protein S, lupus inhibitor assay, activated protein C resistance and quantitation of coagulation factors. The analyzer for specialized testing accepts only 12 X 75 mm tubes. When the rapid response labs receive a coagulation specimen, they perform the routine testing on site and create an aliquot to be sent to the core lab for any specialized tests that are requested.

The core hematology lab team (leader: Laura O'Shea) noted that only 25% of the samples being received for the specialized testing were in the correct tube; 75% of the specimens had to be re-aliquoted and relabeled at the core lab, presenting a potential patient safety risk. The action the team took was simple: They notified the other lab locations that any specimens sent for specialized coagulation testing should be in 12 X 75 mm tubes.

This simple act of communication resulted in an immediate improvement. At three months, compliance was at 93%, and at six months compliance was at 97.5%.

In the histology lab, contamination of patient tissue specimens by extraneous tissue from another patient is a generally recognized problem. These extraneous small pieces of tissue, often called "floaters," are usually easily distinguished from the true specimen. They are typically separate from the actual patient's tissue on the slide and consist of very different tissue types, such as chorionic villi from a placenta contaminating a gastric biopsy. However, sometimes extraneous tissue can be difficult to distinguish from actual patient tissue, especially when the floater consists of only a minute fragment of tumor and ends up closely associated with the actual patient tissue on the slide. The problem can be so important that DNA analysis techniques have been used to help decide whether a small tissue fragment is extraneous.

Improving Single-Piece Processing
Our histology team (leader: Meena Chauhan-Henry) analyzed the steps within multiple processes that could be improved. The team identified that the lack of defined single-piece processing techniques (i.e., addressing only one patient case at a time and keeping different patient tissues separated as much as possible) can contribute to the problem. They also increased the frequency of cleaning grossing and embedding stations, cleaning microtomes during sectioning, changing stains and cleaning forceps.

Contamination rates were measured before and after these interventions; the contamination rate of blocks decreased by 50% and the contamination rate of slides decreased by 63%.

We also compared our rates of extraneous tissue contamination with those reported in a College of American Pathologists national quality assurance (Q-Probe) study.¹ Our final rates of extraneous tissue contamination compared very favorably with the overall extraneous tissue rate reported in the Q-Probe: 0.06% for slides (versus 0.60%); 0.04% for blocks (versus 0.80%) and 0.69% for cases (versus 1.5%). We recognized that the Q-Probe data are from some years ago and that other labs quite possibly have also worked to decrease their contamination rate. Nevertheless this comparison with national benchmark data confirmed our impression that we were doing a good job with contamination.

Formal approaches such as Lean and Six Sigma are often used to improve processes. While such approaches are valuable, our successes demonstrate that even less formally organized attention to communication and attention to process detail can achieve meaningful improvements.

Albert A. Keshgegian is system chairman, department of pathology, Main Line Hospitals, and medical director, Main Line Health Laboratories, Wynnewood, Pa.

Reference

1. Gephardt GN, Zarbo RJ (1996). Arch Pathol Lab Med 120:1009-1014.