Transcript Slide 1
Title: Sending unattended cases to file Owner: AP Lab Ops Group Background: We have experienced a number of “lost” cases that have mysteriously ended up in file without a verified report. Cases stall at various stages of progression (e.g. blocks in file without having been cut, slides in file apparently reviewed as evidenced by dots but without a dictated diagnosis, cases with dictated diagnoses that were never verified, and cases with slides in file that were apparently never reviewed). Investigation/current state: Email received from Dr. Anthony Opipari on 2/5/10 regarding a patient who underwent a diagnostic and therapeutic excision of her uterine cervix on 10/30/09 and for whom no pathology report was available in CareWeb. Email sent after receiving no response to earlier phone conversation with “someone on your staff”. 2/8/10 Friday, 10/30/09 EAA Recommendations: 1. Develop standard work using web based tracking tool to monitor pending work in real time for all signout activities. 2. Task a team to assess and make recommendations for use of the stalled cases report. • New Gross • Diagnosis • Verified 3+ MONTHS! Bx performed at EAA OR Goal No slides or blocks will be returned to file without proof of case progression. Friday, 10/30/09 EAA NOV - FEB COE • GA09-56050 @ 13:25 • GA09-56050 canceled @ 13:26 • GS09-56052 @ 1327 Case surfaces on stalled case report resident/staff changeover Friday, 10/30/09 Friday, 10/30/09 Monday, 11/2/09 History and gross dictated @ EAA by TV, transcribed at 20:33 Blocks created @ 20:24 Slides scanned out of histol @ 07:18* Analysis/root cause: 2/5/10 Phone call/email alert from Dr. Opipari *20/21 GS cases scanned out of histol on 11/2 from 07:18–07:20 verified on 11/3 (17) or 11/4 (3) People Environment lack of visual clarity in signout rooms lack of training/accountability for core competencies (e.g. residents to rotations, admin assists to stalled case report) opportunity to place slides to be reviewed in “to be filed” location no mechanism for holding faculty accountable for assigned cases no standard tool/method for monitoring specific daily demand no tool/mechanism to close the loop when cases delivered to signout rooms case dictated under wrong patient identifier? hand-offs during rotation changeovers pending cases not visible to signing faculty in CSO until diagnosis entered cases diverted from usual workflow (e.g. consult, recuts) disappear from view/attention Method Plan: 1. John Perrin and John Hamilton demonstrated online tool (Laboratory Portal) to residents & fellows (4MAR10) and faculty (8MAR10). • use of the Laboratory Portal will be piloted in the GI (GA) Room and lessons learned shared at April faculty meeting with the goal of gaining consensus regarding standard work/expectations 2. Stalled cases report team (Chris Rigney, John Perrin, Paulette Dozier, Steve Mandell, Raja Rabah, Steve Marshall, Beth Minors) to bring recommendations to AP Ops first week in May for further input, revision, and endorsement. case returned to file without reporting Next steps: 1. Members of AP Ops will return to list of potential countermeasures at next regularly scheduled meeting. 2. Laboratory Portal piloted in GI/GA Room for month of March.