College of American Pathologists
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  Using Lean to end labeling errors


CAP Today




July 2009
Feature Story

The bar-coding initiative in the surgical pathology lab at Henry Ford Health System represented the “Mother experiment” for Lean there, reducing intra­laboratory labeling problems by 85 percent and changing the workflow, says Dr. Mark Tuthill, head of pathology informatics.

“We realized early on that what was going on in the surgical path lab wasn’t smart,” Dr. Tuthill says. “There was a lot of manual labeling using No. 2 pencils, and we were having a lot of errors around labeling.”

So Dr. Tuthill and a Lean team decided that laboratory staff would bar code the patient’s requisition form, the specimen container, the tissue cassettes, and the slides. The approach is what Dr. Tuthill calls the “deli-counter mode of surgical pathology.” You label one at a time, he says, and you label once.

The accessioner enters the patient information on the paper requisition form into the lab information system, CoPath, which generates bar codes for the patient’s test requisition, tissue containers, and cassettes.

“Then downstream at the grossing bench,” Dr. Tuthill explains, “the person can open the CoPath case with the bar code and do the appropriate tissue processing. ... All of the orders for specimens, including special stains and routine, are already in the LIS. The labels for the slides are generated from the appropriate cassettes.”

The pathologist pings the bar code on the slide to open the case in CoPath, says Rita D’Angelo, quality improvement specialist. The pathologist then verifies that he or she has “the correct patient, matching the slide to the information in the LIS and the imaged lab requisition,” and crosschecking the patient history in CarePlus, the hospital electronic medical record.

In rolling out the bar-coding system, Dr. Tuthill and his team had to overcome technological challenges. “It’s not easy to generate bar codes for cassettes, which can’t use linear bar codes,” he says. Instead, “you have to have smaller 2-D or data matrix bar codes.”

To obtain the bar-coding capability, they had to get “creative,” he says, and partner with General Data in Cincinnati, which had created a new cassette labeling system that would listen to the CoPath data and pull out the right fields, format them, and print them onto the tissue cassettes.

“General Data has a bar code that doesn’t fade or scrape off. And the cassettes ping very well when you scan them,” he adds.

For the project, General Data had a software engineer work with the laboratory to create the connection between CoPath and the laser-etching device. “Similarly, we brought [Sunquest Information Systems] in on the CoPath side to ... tell General Data how they would send the data so that GD’s device could listen to it.”

Once the bar-coding system was in operation, “the icing on the cake were the projects that squeezed out the next level of defects and waste,” Dr. Tuthill says.

As one key example, they realized early on that if they were going to be dependent on the bar codes to interact with their work, they had to make sure the bar codes on the cases were accurate. “Otherwise, the bar codes would perpetuate mistakes [down the line].” And “it’s very possible someone could fat finger in a case and stick a label on the requisition form [without noticing] that the name on the CoPath requisition label doesn’t match the name the clinician actually submitted,” Dr. Tuthill says.

So the team implemented several error-proofing steps requiring the accessioner to:

  • scan the requisition form using an optical scanner that creates an image of the CoPath-generated label on the requisition.
  • re-key the demographic identifiers: patient name and medical record number and the surgical path case number.
  • look to the computer to confirm a match between the requisition label generated by CoPath and the requisition provided by the clinician. If there isn’t a match, the computer tells the accessioner to stop. The person then stops the line and fixes the problem.

If the clinician has put the wrong patient identifiers on the requisition form, there’s no way to catch it, though one red flag would be a female part with a male patient’s name, says Dr. Tuthill. (Details about the bar-coding initiative are in a recently published article [Zarbo RJ, et al. Am J Clin Pathol. 2009;131:468–477]).

Most recently, Dr. Tuthill and his pathology informatics team standardized data entry for the CAP cancer checklists. For that project, they worked with Sunquest to incorporate a tool made by mTuitive into the CoPath system.

“The tool forces pathologists to use standard work, entering all the cancer checklist information,” Dr. Tuthill explains. But it’s also “an intelligent tool, so if you answer ‘no’ to one question, then a lot of the other related questions go away.” Without that smart function, the pathologist has to select a lot of “nonapplicable, can’t be examined, and not available answers.”

They have implemented the structured data entry for all 38 of their cancer checklists. “It was a huge project, but in the end, we have been able to produce a much more comprehensive and error-free surgical pathology report, and avoid a lot of downstream repercussions” stemming from an inaccurate one.

Karen Lusky

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