Specimen Identification and Tracking System

Anatomical Pathology Laboratory
Specimen Identification
and Tracking System
A Digital Foundation for
Patient Safety and Beyond
Department of Pathology
Princess Margaret Hospital
Hong Kong
Things That Haven’t Changed In 100 Years
2015
1896
Full of Misidentification Opportunities
PC13-16275
PB12-16275
PB12-16725
Pathologist dictates
gross description
Pathologist requests
additional blocks
Slides with
labels applied
(Gross Room)
(Gross Room)
(Histology)
PB13-16275
PB13-16725
Specimen
arrival
Report
Sign-out
Cassettes preprinted and
placed with specimen
(Gross Room)
PB31-16275
Slides prelabeled by
hand
Pathologist calls up
case to enter
diagnosis
(Histology)
(Offices)
PB13-17265
PB13-17625
= Opportunity for transcription/identification error
Anatomical Pathology
A High-Risk High-Impact Service
Patient ID errors not uncommon
4.3 / 1000 surgical specimens1
1.9 / 1000 amended reports
19.2% of amended reports were due to patient ID
errors2
Risk-prone
Largely manual procedures
Multiple transferring steps from one state to another
during processing
Definitive and Confirmatory Diagnosis
In every malignancy and other serious disease
High impact in patient management
1.
2.
Makary MA et al. Surgical specimen identification errors…. Surgery 2007 Apr;141(4):450-5
Nakhleh RE, et al. Amended reports … Q-probes study of 1,667,547 accessioned cases ... Arch Pathol Lab Med. 1998
Apr;122(4):303-9.
One Incident Is Too Many
Hospital admits wrong breast biopsy specimen
Prostate specimens mixed up
Achievable Error Rates
Error rates
1/100
Error Prevention
Methods
Real world Examples
Clear process
Errors filling out lab requisition
Reliance on
education/vigilance
Failure to give results to patients
Suboptimal specimen
Double checking
1/1,000
Systems for error
identification and
mitigation
1/10,000
Advanced design +
Automation
1/100,000
Error ID/ mitigation
Mislabeled specimens
Specimen loss
Computer interface errors
Resar RK. Making noncatastrophic health care processes more reliable... Health Serv Res. 2006; 41:1677-1689.
Specimen Asset Tracking Errors
Yale University 2010
John H. Sinard, MD, PhD, 2013
What Prevent Barcode From Widespread
Adoption?
• The technology comes with a
significant cost1
• Substantial workflow redesign
• Extra efforts to manage unique
identifiers for sub-samples
• Lacking in most systems2
– Comprehensiveness
– Ability to deal with “exceptions”
– Monitoring tools for complex
workflow
1 Dimenstein IB. Am J Pathol 2009;132:975-6
2 Adaped from John H. Sinard, MD, PhD, 2013
Conventional (On-demand) Approach
Specimen
PB13-17257
Block
PB13-17257
Slide
PB13-17257
Disadvantages of Conventional Approach
• Lack of ability to batch
processing
Slow
Rigid workflow
• Required barcode printing
at every spot of transfer
Costly
Bench space
• Extra effort to generate
unique barcodes
Affect user acceptability
Otherwise limited
functionality
To be solved with
development of dedicated
barcode printers
Smaller
Faster
Cheaper
Even as a tree has a single trunk, but many branches and leaves...
- Mahatma Gandhi
A Novel (Relational Coupling) Design
The new design for better efficiency and cost-effectiveness
Referencing to
relational map
Start
Successful
Print parent item
barcode (e.g.
Specimen ID)
Failure
Correction
Lab
Accession
Block 1.1
Slide
1.1.1
Specimen
2
Block 1.2
Block 2.1
Specimen
3
Block 3.1
Slide
1.2.1
Slide
2.1.1
Slide
3.1.1
Slide
1.2.2
Slide
2.1.2
Slide
3.1.2
Slide
2.1.3
Coupling
Print child items
(e.g. Block ID)
Creation of
relational map
Specimen
1
Transfer specimen
to next processing
step
Relational
Block 3.2
Slide
3.2.1
Innovative Design for Scalability & Adaptability
• Dynamic tree-node
propagation
• Just-in-time parent-child
one-to-one coupling to
specific relational map for
accuracy and flexibility
• Fully integrated with
laboratory workflow
Lab
Accession
Specimen
1
Block 1.1
Slide
1.1.1
Specimen
2
Block 1.2
Block 2.1
Specimen
3
Block 3.1
Slide
1.2.1
Slide
2.1.1
Slide
3.1.1
Slide
1.2.2
Slide
2.1.2
Slide
3.1.2
Slide
2.1.3
Block 3.2
Slide
3.2.1
Conventional vs Novel Approach
Design Philosophy
↔
Handling
one-at-atime

Batch
printing
On-demand
↔
Handling
one-at-atime

Batch
printing
Relational-coupling
Conventional Approach vs. Novel Design
On-demand
Relational-coupling
Better, Cheaper, Faster … and More
Conventional
Novel
Novel
On-demand
Relationalcoupling
Advantages
One-by-one
Matching
Yes
Yes
Equally accurate in
identification
Specimen
Transfer
Sequence
Scan  Print
 Transfer
Print  Scan
 Transfer
Juxtapose scanning and
transfer for greater
security
Pre-printing &
Batching
No
Yes
Reduce cost and more
adaptable to different
workflow
System
Extensibility
Limited
Yes
Readily extensible to
remote task ordering,
inventory monitoring,
specimen disposal etc.
Barcode Tracking & Error Prevention
2
Scanning
1
Preparation
3
Coupling
Putting Patient Safety First
PMH study May 2010 – Apr 2014
Assigning unique 2D barcode identifiers
177,127 specimen containers,
264,204 tissue cassettes,
511,037 slides
No
Misidentification
Incident
All mismatch errors were correctly
signaled to the operating
technician for immediate
correction
When, Where and Who Managing Complex Workflow
Back Bench Process
Process Owner: Denise Bland-Piontek
Reserve for
Resident (may be
significant delay)
OR, Clinics, Consults,
Cytology Specimens
Photo req’d?
Delay
No
Yes
Specimen time
stamped, with
stamper
Y
Small
Grossing
Bench
Y
Back Bench
Specimen
grossed,
placed into
appropriate
cassette(s)
No
More or fewer
cassettes
needed?
Small
Cassettes printed
at cassette printing
station
Y
Large or
Small?
Extra Tissue
Stored
Extra cassettes
placed in bucket
for deletion from
case
Tissue older
than 2 weeks?
Bone?
Yes
Yes
Cassettes printed
at accession area
Yes
No
No
Flow, Micro,
Cytology, or
Stones?
More
Work with
PowerPath to
adjust
number of
cassettes
<10 cassettes
needed?
Yes
Dictation sent to
SoftScript
Cassette
Deletion in
PowerPath,
using Boston
Workstation
Save 6 weeks
No
After 8:30AM
and Same Day
Rush?
Legal Case,
Save or
Medical
Device?
Decalcification
M.D.
Legal, Medical
or Save?
Legal
Tissue Stored
Indefinitely
Save
Client Want?
No
Yes
Yes
Cytogenetics?
Requisition hand
delivered to
Transciption
Cassettes placed
in racks, photo of
rack taken for
tracking purposes
Specimen Hand
Delivered to
Histology
No
No
Y
Specimen
logged in
PPTH, labels
printed
Specimen sent to
Histology
Same Day
Rush?
Yes
Yes
Paper log
Send to
Cytogenetics, Flow
Cytometry,
Microbiology,
Cytology Cell
Block, Stones,
Molecular
End
Yes
Gross Only?
Specimen
received, logged
(Accessioning)
Add ribbon and
note with
instructions to
cassette
No
No
No
Yes
Requisitions
batched, sent to
transcription
Accessioner walks
to Gross, tech cuts
specimen sample
Specimen
sample sent
to Tumor
Bank
Special
Instructions?
Large
Send to
Transcription
for Accession
N
Tumor Bank?
No
Upload to
pat_dim2
Fewer
Frozen
Section
Process
N
MGH Consult?
Take a photo at
photo station
Requisition Form
Needed for
resident?
Frozen
Section?
Yes
No
Return to client
Tissue discarded
No
Enter case and
number of
cassettes into log
Access
Task and Process Management
Printing & unique
2D barcode
assignment
Pathologist
ordering special
studies
Task processing
Task finalizing
Coupling
Specimen Inventory
Awards & Recognitions
An endorsement of Quality
Hospital Authority Best Poster
Presentation Award in the New
Advances in Care Delivery 2014
Hospital Authority Best Oral Presentation
Award in the Quality and Safety 2013
Hong Kong ICT Award 2015
Bronze in “Best Smart Hong Kong”
Joint Hong Kong Academy of Medicine – Medical
Protection Society Excellence in Patient Safety
Award 2014
Outstanding Team Award 2014 of the Hong
Kong Hospital Authority
Quality Service for Everybody
•
Implemented in all HA hospitals
–
Starting from 3 different clusters – KWC,
HKEC and NTWC
– Accounting for about 500,000 surgical
specimens annually
– Issuing over three million unique barcodes
per year
• Potential for large-scale implementation
– Department of Health
– Private and overseas hospitals
Implemented in All Public Hospitals