Improving the Accuracy of
Dermatology Specimen Labeling
Susan Y. Chon, M.D.
Assistant Professor
Department of Dermatology
UT MD Anderson Cancer Center
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
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
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.
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
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%
Total
specimens
2009
1
Gastrointestinal
18,144
2
3
4
5
6
7
8
9
Genitourinary
Skin
Breast
Head and Neck
Gynecology
Thoracic
Soft tissue
Neuro
14,620
14,529
11,676
9955
5665
4885
1961
1879
10
11
12
13
Bone
Hemepath
Cytology
Unassigned
Total
1543
1480
228
137
86,702
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:
1.
2.
3.
4.
MRN
Labeling Defects
Provider
Information re: discovery
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.
Baseline Data – Defect Types
“No site written” was the primary defect type, followed by
“Wrong patient name” and “Illegible handwriting. ”
Total defects at Baseline
 Baseline surveillance for two weeks
between February 15- February 26,2010
 Total errors = 13/172
 Error rate = 7.6%
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.
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
Proposed Modified Flow
(Intervention)
The new flow is based on
the benchmark, modified
as appropriate for use in
the main clinic.
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
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
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
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
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