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Samtrak: HTML Embed

Samtrak (Sample tracking)

A project to minimize pathology specimen loss.

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Background

  • 23% of most recent errors reported in dermatology practices were pre-analytical sample tracking errors [1].

  • 10% of most serious errors reported in dermatology practices were pre-analytical sample tracking errors [1].

  • Biopsy pathway has about 20 steps, and errors can occur at any step [2].

  • An estimated 17% of pathology sample identification defects result in incorrect therapy, and nearly 6% cause adverse events [3].

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Problem

  • 24 pathology specimen errors were reported in our department in 2019.

  • 5 specimens were lost, 5 more were near misses.

  • Analysis of the biopsy process revealed areas of weakness and significant variability between sites and providers.

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Goal

To minimize the loss of pathology specimens by strengthening the process and reducing interprovider variability.

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Interventions

  1. Define biopsy process.

  2. Strengthen biopsy process using the Pareto principle. 

  3. Create visual aids.

  4. Implement a checklist.

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Results

We are currently collecting post-intervention data.

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Resources​

Our work is licensed under Creative Commons Attribution License. Please give credit to UCSF Dermatology QI team by linking to dermquality.org

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References

  1. Watson AJ, et.al. Medical error in dermatology practice: development of a classification system to drive priority setting in patient safety efforts. J Am Acad Dermol 2013;68:729

  2. Stratman EJ, et.al. Biopsy: Identifying and Overcoming Errors in the Skin Biopsy Pathway. J Am Acad Dermatol 2016 Jan;74(1):19-25.

  3. Bixenstine PJ, et.al. Developing and Pilot Testing Practical Measures of Preanalytical Surgical Specimen Identification Defects, J Cutan Pathol 2015;42:33.

Samtrak: Text
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