Improving Patient Safety through Communication

Involved in the Patient Safety Net process since 2004, Surgical Pathology submits an average of twenty-five events each month.

Defects reported through PSN include but are not limited to:

  • Unlabeled specimen/s
  • Missing specimen description\
  • Incorrect laterality (e.g. right vs left breast)
  • Mismatched information (specimen vs requisition)

As the result of educating Surgical Pathology staff on the importance of reporting specimen defects, an astounding 139 PSN events were reported by the laboratory in October of 2009.

Alarmed at the significant and sudden variance, the Quality Assurance Specialist compiled the 2009 PSN data. The clinic sites exhibiting the highest number of defective specimen or requisition submissions were identified. The Surgical Pathology Education Coordinator contacted the clinic managers of these sites and offered on site in-service education.

The educational sessions provided the clinic staff valuable insight in understanding the importance of providing the laboratory with accurately labeled specimens and requisition forms.

These discussions also provided the clinics with a forum to discuss how they can re-train their staff to prevent these defects occurring again, as well as giving the laboratory an insight into the staffing and logistical problems each clinic is faced with.

Suggestions and improvements were personalized for each clinic based on what problems the clinics had and what defects they created; including re-training, improved communication, surgical pathology tours and defect feedback from the laboratory.


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Download Arlene Prescott’s PowerPoint presentation, Surgical Pathology Submission Requirements for more information.

Doris Deane, Arlene Prescott and Hazel Richardson

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