10.17.2008

Mistakes on Specimen Bottles Prompt a Lean Study

Radio-frequency identification (RFID) tags on specimen bottles can help reduce errors in biopsy analysis, according to a new study by the Mayo Clinic.

That may sound like a fairly narrow, clinical issue, but I suspect it is bigger than that. And the study contains some intriguing suggestions of a lean approach.

The study, reported by The Washington Post, notes that the clinic’s Gastroenterology and Colorectal Surgery outpatient endoscopy unit (how’s that for a name) sends out more than 30,000 specimen bottles a year for pathologic reviews. And that is just one clinic.

How often do errors occur? The article says the study found 765 errors out of 8,231 specimen bottles (that’s 9.3 percent), with the errors consisting primarily of either the wrong patient label or no label being affixed to a specimen bottle.

But the rate dropped to 47 errors out of 8,539 bottles (0.6 percent) after a quality improvement initiative.

And from a lean standpoint, that is the interesting part. Use of technology like RFID tags is not in itself lean. But the decision to recommend the tags stemmed from a focus in the initiative on “correct data creation and transcription point reduction,” according to a news release. That sure sounds like an effort to find and attack the root cause of the problem – which does sound lean.

The Post article doesn’t discuss the consequences of errors on specimen bottles. I imagine these could range from a test having to be re-done to a patient being treated incorrectly.

I have a little concern about the recommendation. I suspect a lot of hospitals will be reluctant to spend money on new technology like RFID. And I can’t help but wonder whether there is a simpler (leaner?) and less costly solution.

However, I’m glad the Mayo Clinic conducted this kind of study, and I hope they do more in the future. I also hope the people there do think in lean ways.

1 comments:

Dean Bliss said...

I suspect the "technical" solution had more to do with the high volume than the desire to necessarily use technology. Mix-ups can have tragic consequences, like the recent news story of the woman who had a double mastectomy that was proven to be unnecessary due to a lab labeling error. We need to find the simple, elegant solutions to prevent these type of errors from happening. Application of RFID in this case is an interesting one.