Getting It Right for Patient Safety

Abstract

Objectives: Specimen labeling defects within the perioperative environment are a known patient safety risk that carries the potential for adverse outcomes. These outcomes are a result of errors that occur when unsuspecting providers operate within poorly designed processes with little control over the specimen collection context. Many costly outcomes resulting from labeling errors may include patient harm, inappropriate treatments, lengthy investigations, corrective actions, and, at times, legal action. Methods: This improvement initiative to identify and reduce the risk of specimen labeling defects includes the application of a disciplined Lean problem-solving approach with the engagement of employees who actually perform the work. Results: By listening to the voice of our internal customers, we collectively redesigned the workflow by collaboratively linking work teams of the operating room and Pathology Department of Henry Ford Hospital, Detroit, over a 2-year period. Conclusions: We illustrate successful interventions achieved by Lean process management by streamlining, standardizing, and mistake proofing the processes and eliminating waste and inefficiency through systematic problem solving.