Portal de Periódicos da CAPES

The Henry Ford Production System

2009; Oxford University Press; Volume: 131; Issue: 4 Linguagem: Inglês

10.1309/ajcpptj3xjy6zxdb

1943-7722

Richard J. Zarbo, J. Mark Tuthill, Rita D’Angelo, R Varney, B Mahar, Cheryl Neuman, Adrian Ormsby,

Clinical Laboratory Practices and Quality Control

Misidentification defects are a potential patient safety issue in medicine, including in the surgical pathology laboratory. In addressing the Joint Commission's national patient safety goal of accurate patient and specimen identification, we focused our lens internally on our own laboratory processes, with measurement tools designed to identify potential misidentification defects and their root causes. Based on this knowledge, aligned with our lean work culture in the Henry Ford Production System, we redesigned our surgical pathology laboratory workflow with simplified connections and pathways reinforced by a bar code technology innovation to specify and standardize work processes. We also adopted just-in-time prestain slide labeling with solvent-impervious, bar-coded slide labels at the microtome station, eliminating the loop-back pathway of poststain, batch slide matching, and labeling with adhesive paper labels. These changes have enabled us to dramatically reduce the overall misidentification case rate by approximately 62% with an approximate 95% reduction in the more common histologic slide misidentification defects while increasing technical throughput at the histology microtomy station by 125%.