Frozen-Section Checklist Implementation Improves Quality and Patient Safety

• Published in: American journal of clinical pathology Vol. 151; no. 6; pp. 607 - 612
• Main Authors: Chen, Yigu, Anderson, Kevin R, Xu, Jia, Goldsmith, Jeffrey D, Heher, Yael K
• Format: Journal Article
• Language: English
• Published: England Oxford University Press 01-06-2019
• Subjects: Care and treatment; Checklist; Defects; Diagnosis, Surgical; Frozen Sections; Frozen tissue sections; Humans; Intraoperative Period; Labeling; Methods; Pathological laboratories; Patient Safety; Patients; Quality control; Quality management; Referral and Consultation; Safety; Statistical analysis; Time Factors; United States; Patient safety; Intraoperative consultation; Quality improvement; Safety; Frozen section
• ISSN: 0002-9173; 1943-7722
• DOI: 10.1093/AJCP/AQZ009

An intraoperative consultation (IOC) checklist was developed and implemented aimed at standardizing slide labeling and monitoring metrics central to quality and safety in surgical pathology.
Data were collected for all IOC cases over a 9-month period. Slide labeling defect rates and IOC turnaround time (TAT) were recorded and compared for the pre- and postimplementation periods.
In total, 839 IOC cases were analyzed. Preintervention slide labeling showed that 85% of cases contained at least one defect (n = 565). Postintervention data revealed that 27% of cases contained at least one defect (n = 274). The improvement was statistically significant (P < .001). Mean TAT was 21.6 minutes preintervention vs 23.2 minutes postintervention, and the change was insignificant (P = .071).
The implementation of a standardized IOC reduced slide labeling error. This improvement did not affect mean TAT and may have the increased quality of IOC TAT data reporting. Other metrics affecting patient safety and quality were monitored and standardized.