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As an adjunct to Lean working, CEREBRO specimen tracking provides assurances of enhanced patient safety and improved efficiency throughout the laboratory workflow in a large UK hospital Trust
Paul Williams MSc CSc FIBMS
Head Biomedical Scientist Cellular Pathology,
East Kent Hospitals University NHS Foundation Trust, UK
East Kent Hospitals University NHS Foundation Trust (EKHUNFT) is one of the country’s largest NHS Hospital Trusts, serving a population of 759,000 comprising five hospital sites: Buckland Hospital, Dover; Kent and Canterbury Hospital, Dover; Queen Elizabeth The Queen Mother Hospital, Canterbury; Royal Victoria Hospital, Margate; Folkestone and the William Harvey Hospital, Ashford.
The Cellular Pathology department provides a centralised service for the population of East Kent located at the William Harvey Hospital, Ashford. The laboratory provides a routine histopathology service and Tables 1 and 2 show average weekly slide production and annual workload, respectively.
To maintain and keep up with this growing workload (6% per annum), we apply Lean principles and embrace modern technology wherever possible to provide a safe and efficient service, which includes digital voice recording, speech recognition and specimen tracking.
Histology remains traditionally a collection of predominantly manual processes easily divided into definable and auditable stages. Prior to CEREBRO specimen tracking technology introduction, we were reliant upon a combination of laboratory information system (LIS)-generated and manual data collection throughout the workflow, which was often incomplete or missing and of unreliable quality, making workflow analysis difficult and often of limited value. LIS for cellular pathology are usually based upon Biochemistry programs, lacking sufficient data fields necessary to monitor the histology workflow accurately.
After an initial six-month pilot in 2013 with the Leica Biosystems CEREBRO specimen tracking solution with 2D barcode technology,1 we fully implemented CEREBRO in the summer of 2014 (Figures 1–4). The CEREBRO pilot had proven it was able to significantly improve patient safety and facilitate the management of the workflow with effective monitoring of each part of the process.
Any change to established methodologies and processes usually meets with an element of resistance, but staff accepted this technology very quickly. Staff were already engaged in continuing change as a result of previous Lean projects to improve workflow.
There were several key stages to the configuration process:
Staff could see the clear advantages of replacing ‘eyeball checking’ of unique patient and specimen identifiers with the barcode technology.1
Staff felt reassured that the barcode scanning at each part of the process gave confidence of accuracy of patient and specimen identifier quality cross checks and therefore patient safety. Our experience pre-CEREBRO had found that the majority of errors occur in the pre-analytical phase3 (see Table 6), such as accessioning, grossing, embedding, microtomy and case assembly. Such errors occurred in approximately 0.25% of cases.2
Mismatched specimens could potentially pass through the workflow unnoticed with a risk of a specimen being processed and reported for the wrong patient resulting in misdiagnosis. CEREBRO provides a robust system1 that tracks and verifies the identity of every specimen at every point of the workflow. Nothing is left to chance, virtually eliminating human identification errors and includes checks to ensure any potential problem is identified before there is a risk to patient safety. Six months into the full implementation, the pre-analytical mislabelling errors have already reduced to 0.12%.
Human errors still occur and are related to staff not following correct CEREBRO checking protocols. Further reduction in mislabeling errors will occur as we re-enforce protocols through competency checking.
CEREBRO specimen tracking has clear patient safety advantages as indicated in Table 7. (All processes in red font have a risk of human error). Staff have the ability to scan a barcode and feel confident that identifiers are being compared and matched throughout the process, significantly reducing the need for “eyeball” checking and the subsequent impact on ensuring the correct specimen is for the correct patient.
Improved patient safety due to tracking at each step in sample preparation
Use of barcoding to automate sample tracking has replaced the need for ‘eyeball’ checking
Efficiency of automated sample tracking and enhanced productivity
In addition to patient safety, CEREBRO offers the ability to monitor quality by attaching a note to an individual specimen, cassette or slide at any step of the process. These notes are auditable against an individual and client workstation. In East Kent we are developing key quality indicators to monitor processes within the laboratory using the audit trail of notes posted. Using CEREBRO’s ability to date and time stamp every part of the process and identify the client and individual user it is possible to record and therefore count per individual the various quality issues identified within Table 4. We will be able to produce quality indices from this data and accurate staff performance profiles that will assist in managing the performance of individual members of staff, offering training support where needed or process changes to continually improve the quality of the work we do.
For example, a member of staff who routinely cuts 20 routine sections per hour but has on average three slides rejected for every 20 blocks cut. This would produce a rejection rate of (number of Blocks rejected/total blocks cut) x 100 = (3/20) x 100 = 15%
This simple calculation will be applied to the different quality issues within the QC category listed in Table 4 for the sectioning client. This will produce a competency profile for each microtomist and the laboratory as a whole with indices for quality improvement. The same approach will be applied to other parts of the process such as embedding.
CEREBRO specimen tracking has resulted in efficiencies is specific areas as shown in Table 8. There will be continuing efficiency improvements arising from an improved understanding of the workflow using the data provided by the CEREBRO dashboard to continuously improve the workflow.
There are some activities, such as Pathologists scanning cases to themselves, that have a small negative effect on time saved, but the ability to track who has what case has reduced interruptions to reporting when laboratory staff have to locate cases for multidisciplinary team meetings.
Efficiency is also enhanced by CEREBRO’s ability to produce exception reports that can list specimens that are going to breach set turnaround times at different stages of the process. These include:
We are able to minimise breaches to turnaround times by using these data to prioritise cases.
Risk mitigation and removal of human error
Pre-CEREBRO specimen tracking system errors
Impact of CEREBRO specimen tracking
Errors only occur when staff do not follow the correct procedure; this is audited by regular competency assessments.
CEREBRO specimen tracking has provided a safe mechanism with the use of 2D barcodes for ensuring the specimen and patient identifiers match throughout the journey of a patient’s specimen(s) from receipt, to diagnosis, to archive. As users have to log into each client with a unique access code, and all activity is time- and date-stamped with a complete audit trail, accurate individual and laboratory performance can be measured using the real-time tracking tools and dashboards. In addition, quality improvements can be assessed for individuals and for the laboratory overall.
As an adjunct to Lean working, replacing manual and paper-based systems, CEREBRO specimen tracking has provided assurances of enhanced patient safety compared with previous manual systems as well as releasing some efficiency throughout the process flow. This provides a high level of confidence that the slides the Pathologists are reporting and requesting extra tests on are for the correct patient.