INTRODUCTION OF A DOUBLE-VERIFICATION CHECKLIST FOR ENDOSCOPY PATHOLOGY SAMPLES: A QUALITY IMPROVEMENT PROJECT

Aims:

Improvement of patient safety and quality in endoscopy is of utmost importance. Of late, more emphasis has been placed on improvement of technical skills and key performance indicators than examining non-technical skills and human factors for error. In Bantry General Hospital (BGH) there was high number of pathology specimens taken at endoscopy rejected for analysis due to specimen mislabeling. This represented a major breach of patient safety. A Quality improvement (QI) project was undertaken within the endoscopy department using the PDSA approach with the aim of error reduction.

Methods:

Plan:

The standardized Safety Attitudes Questionnaire (SAQ) was administered to the nine departmental staff members to assess the baseline safety opinions of staff.

Do:

A double-verification checklist was introduced within the department to reduce labeling errors.

Study:

Pathology errors for a year post checklist introduction were reviewed and a qualitative feedback questionnaire administered to staff.

Act:

Qualitative feedback gave scope for expansion of further QI projects within the department.

Results:

The baseline specimen rejection rate was 1.92%. Introduction of a double-verified safety checklist lead to an 88% reduction in labeling errors. A high positive score has been demonstrated in all categories of the SAQ in the endoscopy unit in BGH indicating a strong culture and safety attitude present within the unit. A qualitative analysis of why errors occurred drew up two main themes, namely process and human factors. Advantages of the new checklist were outlined under the themes of quality factors and process factors. The time constraints of the new process was the main cited disadvantage.

Conclusions:

Introduction of a double-verification safety checklist in BGH successfully reduced error in specimen labeling rates in endoscopy in the context of a strong safety culture within the unit. The study highlights the benefits of safety checklists in the endoscopy process as a means of improvement of patient safety.