Successful applicants to the ASGE Endoscopy Unit Recognition Program submit a summary of a recently conducted quality improvement (QI) project as part of the application process. The quality assurance and performance improvement (QAPI) project in the spotlight this month looked at pathology specimen reconciliation.
Purpose of QI activity, description of known or suspected problems and explanation of its significance to the organization:
To see a decrease in the number of errors on pathology reports upon reconciling. These errors are a combination of mistakes from [pathology company] and [endoscopy unit] staff. A corrected report is requested from [pathology company] upon finding the discrepancy, which causes a delay in the doctors receiving the pathology results. [Editorial Note: This also delays the patient receiving the pathology results and causes additional, unnecessary worry and anxiety.] The corrected report is labeled as such, so when the doctors sign for their pathology, they are aware of why there was a delay in receiving results.
Identification of the performance goal against which the organization will compare its current performance:
We would like to see a decrease in the total number of discrepancies, with the number of staff errors being zero by the end of the second quarter.
Description of the data that will be collected to determine the organization’s current performance:
Date: January 2023
Each discrepancy is logged with the following:
- Description of the error (i.e., specimen labeled sigmoid but reported as cecum)
- If the error was from [pathology company] or [endoscopy unit] staff
- Date the corrected report was requested and received
Evidence of data collection:
Date: January
Monthly discrepancy logs are kept with the total number of cases that had pathology sent and the total number of errors. This will also show if the error was from [pathology company] or [endoscopy unit] staff.
Data analysis that describes findings about the frequency, severity and sources of the problem:
All pathology reports were audited for January, which was 245. Of those 245 cases, there were eight errors, with five made by [pathology company] and three made by [endoscopy unit] staff.
A comparison of the organization’s current performance in the area of study against the previously identified performance goals:
Date: January 2023
The total number of errors made by [endoscopy unit] staff with pathology reports in January was five. Our goal is zero errors by staff, so our goal was not met. QI study to be initiated.
Implementation of corrective actions to resolve identified problems:
Date: February 2023
At our February staff meeting, the following was discussed, and new processes were put into place. The following reminders will be placed in the pathology binder:
- Does the patient’s name, DOB, and MRN match those on the pathology requisition from [endoscopic report writer software] with the patient label on the specimen jars and pathology log?
- Does the patient's name on their photo ID match with the pathology requisition and patient label?
- Are the specimen jars labeled exactly as is listed on the [endoscopic report writer software] pathology request?
- Room nurses were educated on the types of discrepancies that are being found.
- Room nurses were educated on the importance of verifying that patient and specimen information match those on the pathology requisition generated from [endoscopic report writer software], patient sticker and demographics.
Remeasurement with a second round of data collection to objectively determine whether the corrective actions have achieved and sustained demonstrable improvements:
Date: March 2023–June 2023
March 2023: 320 pathology reports audited. 24 errors were reported, with 21 made by [pathology company] and three made by [endoscopy unit] staff.
April 2023: 281 pathology reports audited. Six errors were reported, with five made by [pathology company] and one made by [endoscopy unit] staff.
May 2023: 342 pathology reports were audited. Nine errors were reported, with all nine errors made by [pathology company]. Zero errors were made by [endoscopy unit] staff.
June 2023: 347 pathology reports were audited. Five errors were reported, with all five errors made by [pathology company]. Zero errors were made by [endoscopy unit] staff.
If the initial corrective actions did not achieve and/or sustain the desired improved performance, implement additional corrective actions and continue remeasurement until the problem is resolved or is no longer relevant:
The [endoscopy unit] goal of zero pathology errors made by [endoscopy unit] staff when reconciling pathology is met. There is no need for remeasurement.
Communication of the findings of the quality activities to the governing body and throughout the organization, as appropriate, and incorporation of such findings into the organization educational activities:
Date: April 25, 2024
Results of the study were reported to the clinical director and administrator. The clinical director presented the results to the [endoscopy unit] physicians and governing board.
We hope sharing this project summary will be useful to you and your practice.