Wrong Tissue in Block: Grossing Gone Wrong Can Be Made Right With Tailored Informatics Solutions. Issue 4 (3rd May 2021)

• Record Type: Journal Article
• Authors: Weaver, Kaitlin D; De Los Santos, Yanel; Gaffar, Maira; Zona, Melanie C; Gennaro, Tyler; Shenoy, Archana; Flax, Sherri; Chamala, Srikar; Seifert, Robert P; Esnakula, Ashwini K
• Is Part Of: American journal of clinical pathology. Volume 156:Issue 4(2021)
• Page Start: 700
• Page End: 707
• Publication Date: 2021-05-03
• Subjects: Wrong tissue in block -- Grossing errors -- EPIC Beaker Laboratory Information System; Diagnosis, Laboratory -- Periodicals; Pathology -- Periodicals; 616.07
• DOI: 10.1093/ajcp/aqab011
• Languages: English
• ISSNs: 0002-9173

Abstract

Abstract: Objectives: Maintaining specimen identity during surgical pathology tissue processing is critical. Epic Beaker Laboratory Information System requires sequential scanning of specimen label and grossed blocks (block confirmation) to ensure specimen identity. We report our institution's experience with wrong tissue in block (WTIB) grossing errors before and after adopting block confirmation. Methods: During the first 18 months of Beaker implementation, block confirmation was not required. We then mandated block confirmation for a 3-month period. To ensure compliance, we then built a "hard stop" feature that prevents scanning any unconfirmed blocks onto a packing list. We reviewed WTIB incidents pre- and postimplementation of these solutions. Results: Before using block confirmation, we had WTIB incidents involving 17 (0.043%) of 38, 848 cases. When we mandated block confirmation use, we had WTIB involving 2 (0.043%) of 4, 646 cases. After implementing the hard stop feature, we had WTIB incidents involving 2 (0.005%) of 42, 411 cases. Overall, there was an 88.4% (0.043% vs 0.005%; P < .001) reduction in WTIB incidents using block confirmation with a hard stop. Conclusions: Beaker is a customizable platform that can be tailored to a laboratory's workflow. By using barcoding, implementing custom-built features, and improving workflow protocols, we significantly reduced WTIB errors.