Fixing the Anatomic Pathology Lab's Top Ten Disasters--Before They Happen!

Executive War College 2011New Orleans, LA

Discussion Points

• Why is there a focus in Pathology?

• What are the top ten disasters? Which are most important?

• What solutions should be considered?

• How to start?

Why Focus on Pathology? ----- Its in the News!

• Reported impact of medical errors

• Increase in litigation

• Increased testing - baby boomers

• Cost of new technologies

• Industry consolidation

• Number (or lack) of employees

Question: Are there really that many risks?

Answer: Probably a lot more! So..

• Not Looking for Problems

• Over-worked/No Time

• No Ownership

• Neglected Issues

Example: Breast tissue fixation

↓

If 50% of the 1.3MM diagnosed

women tested

↓

650,000 patients impacted

0.5% sample labeling error

↓

150MM samples globally

↓

750M patients impacted

Why don’t we“see” problem

areas?

Potential Disasters – 3 Key Areas

LabelingErrors

Work ProcessFlaws

EnvironmentalFactors

1

2

CollectionSite

AccessionSite

4

3

5

In-LabProcessing

ReadingSite

6

7 10

8 9

“Lost”Tissue

Over-Processing

Over-Production

TransportManagement

HazardousMaterials

EquipmentPlacement

Potential Disasters – Labeling Errors

LabelingErrors

Work ProcessFlaws

EnvironmentalFactors

1

2

CollectionSite

AccessionSite

4

3

5

In-LabProcessing

ReadingSite

6

7 10

8 9

“Lost”Tissue

Over-Processing

Over-Production

TransportManagement

HazardousMaterials

EquipmentPlacement

1. Labeling Errors – Collection Site

If mis-identified at point of origin, why analyze?

• Specimens are mis-indentified, but the diagnosis may appear correct

• Cases that don’t make clinical sense

• OR staff admit “We mixed up the specimens”

• Audits are rarely conducted to check identification

Can We GainControl OverThe Labeling

Process?

2. Labeling Errors – Accessioning Site

Are addressograph labels on lids?

Is the accessioning

area cluttered?

Are there excessive

phone calls?

Are excess labels in use?

3. Labeling Errors – In-Lab Processing

Are cassettes kept in

order?

Is the original block used for

re-cuts and special stains?

Are hand-written labels

in-use?

Do distractions make it hard to

complete or pass-off work?

4. Labeling Errors – Reading Site

Final Reports -

• Are bar-codes used to match slides and report formats?

• Are patient numbers read from the slide while it is on the microscope stage and dictated to the report?

• What is the dictation process, is it error-free?

• Are hand written numbers (using a mirror) matched to the slide label?

Potential Disasters – Work Process Flaws

LabelingErrors

Work ProcessFlaws

EnvironmentalFactors

1

2

CollectionSite

AccessionSite

4

3

5

In-LabProcessing

ReadingSite

6

7 10

8 9

“Lost”Tissue

Over-Processing

Over-Production

TransportManagement

HazardousMaterials

EquipmentPlacement

5. “Lost Tissue” in the Processor

• What steps are taken to ensure proper processing?

• Are special techniques (foams) seen as too expensive?

• How much do we actually save? Is it worth having to re-biopsy a patient.. And can we even get another biopsy?

6. Over-processing Tissue

• Too much time spent in the processor to keep it to one daily run

• Overloaded processors

• Tissue source isn’t always considered

• Backup processors are avoided

• Staff schedules may not match workload

• Delays if processor is full

7. Over-production – “Extra” slides

Let’s spend time saving time……… making an extra slide or cassetteon every case saves time, right?

• NO! - time is wasted making too much “stuff”

• Since slides are “just in case”, are they properly labeled?

• How much time is spent looking, if and when we need these slides?

Potential Disasters – Environmental Factors

LabelingErrors

Work ProcessFlaws

EnvironmentalFactors

1

2

CollectionSite

AccessionSite

4

3

5

In-LabProcessing

ReadingSite

6

7 10

8 9

“Lost”Tissue

Over-Processing

Over-Production

TransportManagement

HazardousMaterials

EquipmentPlacement

8. Equipment Placement

Improper placement of equipment can create inefficient mazes and hamper productivity.

• Is equipment placed where “it fits” or where “it belongs”?

• Is time is spent running back and forth?

• How much time/money is saved in doing it right?

9. Hazardous Materials - Fumes/Vapors

Histology has serious risks due to hazardous materials

• New technologies are available to clear formulin/xylene fumes– Properly designed ventilation of counter tops– Engineered hoods for dissection– Sinks that recycle solvents without open containers

• Materials are corrosive and damaging to finishes – It’s only going to get dirty again…– Materials and processes to keep staining to a minimum– Daily/routine cleanup can keep it nice

10. Materials – Storage & Transportation

MSDS provides guidance on how to store and transport hazardous materials. But-------

• What could go wrong?– A gallon of glacial acetic acid is dropped putting it into a

safety container– Fumes mix with other chemicals creating a toxic

atmosphere– When to evacuate the lab, the hospital– MSDS sheets are inconveniently located

Solutions for Key Areas

LabelingSolutions

Work ProcessSolutions

EnvironmentalSolutions

Solutions – Labeling Errors

• Take time to understand the current process

• Try to understand where “breakdowns” occur in the process

• Involve stakeholders in developing solutions (this means talking with and to Nurses and Doctors!)

• Education is key

• Don’t give up! Listen!

Identification at Collection

Organized work ready for the PA’s – No Reason for Clutter!

• Each bin contains the same number of cases

• All materials are placed in one compartment

• The number is small enough to be efficient yet practical

Containers “Contain” the Problem

Solutions – Labeling Errors

• Move to Single Specimen Processing

• Never take your eye off the specimen!

• Look at your current LIS to see if there are any solutions available with it

• Think Outside the Box!

• Only Automate processes you really understand!

Identification In the Lab• Move to Single Specimen Processing

• Never take your eye off the specimen!

• Look at your current LIS to see if there are any solutions available with it

• Think Outside the Box!

• Only Automate processes you really understand!

Identification In the Lab• Move to Single Specimen Processing

• Never take your eye off the specimen!

• Look at your current LIS to see if there are any solutions available with it

• Think Outside the Box!

• Only Automate processes you really understand!

Identification In the Lab

Error Reduction Analysis

2009 2010% Error Reduction

Jan 7 7 0%

Feb 11 6 45%

Mar 15 4 73%

Apr 14 0 100%

May 9 1 89%

Jun 12 2 83%

Jul 16 1 94%

Aug 10 3 70%

Sep 4 1 75%

Oct 3 3 0%

Nov 16 2 88%

Dec 4 1 75%

TOTAL 121 31Average Error Reduction 72%

ImprovementSingle Magazine Cassette Labeler

• Cassettes are labeled as they are needed

• Cassettes are never made in anticipation

• Color coded cassettes distinguish types of cases

Positive ID of Cassettes• Cassettes are labeled as they are

needed

• Cassettes are never made in anticipation

• Color coded cassettes distinguish types of cases

Positive ID of Cassettes

Solutions - Work Process Flaws

In-Lab Work Process

What and where equipment is placed can reduce the amount of staff time to get from process to process and greatly reduce the risk of error.

• Walking extra steps increases the risk of work distractions

• Wasted “foot-steps” add-up day- after-day

• Value stream maps help to outline where non-valuesteps occur.

Solutions – Work Process Flaws

• Staff schedules should match to workload

• Spread use of processors across shifts

• Specimen type must be considered - use of backup processors as needed

Solutions – Hazardous Materials

• Take a realistic approach to storage of materials– Segregate materials and store in a manner that makes sense– Use protective containers for storage– If not, can we keep the clean up data (MSDS sheets) on line or in

an area that can’t be affected by a spill or accident?

• Fumes and smells are a hindrance– Absenteeism due to respiratory distress – When remodeling take the time/expense to fume-proof!

• Error Proof the process to eliminate risks of spills– Alarms alert that the container if full– Containers on wheels to ease recycling

Formalin Decanting Kaizen

• Before engineering the final solution, a temporary trial system was created

• Problems detected with the experiment were eliminated in the final version

• Data used to create the final version

Started as an Experiment

New Formalin Waste &  Empty Container Drop

• Formalin is directly disposed of through a strainer directly into recycling carboy

• Empty containers are deposited into a storage bin under the counter

• The final version error proofed and improved the process

Formalin Disposal

New Formalin Waste Receptacle

• The experimental “hose” lead to the final chemical resistant slip-lock piping

• Alarms eliminated the possibility of overfilling

• Wheels and slip fittings prevents spills, lifting injury, and expedites recycling

Thinking Out of the Box!

Where to Start? -----Understand the Process

• Create a value stream map

• Conduct a “brown paper” exercise to identify details

• Introduce an “outsider” to the process

• Recognize that it takes work to understand and “fix” a broken process.