Reducing Labeling Errors in Histopathology Specimens: A Quality Improvement Initiative on Endometrial vs. Endocervical Specimens to Promote Patient Safety in KK Women’s and Children’s Hospital

IF 3 Q2 HEALTH CARE SCIENCES & SERVICES

Joint Commission journal on quality and patient safety Pub Date : 2026-01-01 Epub Date: 2025-10-28 DOI:10.1016/j.jcjq.2025.10.006

Yash Bhanji Boricha MBBS, DGO, MS, DNB, MRCOG (is Senior Staff Physician, Department of Obstetrics and Gynaecology, KK Women’s and Children’s Hospital, Singapore.), Junzhe Zhao MA, MEng, PhD (is final year MD/PhD candidate, Duke-NUS Medical School, Singapore.), Felicia Yiqian Ang (is PSQ Lead, Department of Quality, Safety and Risk Management, KK Women’s & Children’s Hospital.), Kim Teng Tan MBBS, MMed, MRACOG, FAMS (is Senior Consultant, Division of Obstetrics and Gynaecology, KK Women’s and Children’s Hospital. Please address correspondence to Junzhe Zhao)

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引用次数: 0

Abstract

Background

Mislabeling of endometrial vs. endocervical curettings was the most frequent specimen error in the Division of Obstetrics & Gynaecology at KK Women’s and Children’s Hospital, Singapore. These look-alike/sound-alike (LASA) errors can compromise patient safety and workflow efficiency. The authors aimed to reduce specimen labeling errors over a two-year quality improvement (QI) period.

Methods

Following root cause analysis, a multidisciplinary QI project was initiated in a single tertiary obstetrics & gynecology center using the Plan-Do-Study-Act (PDSA) methodology. Between 2020 and 2022, interventions were (1) a pilot system-level enhancement to the electronic ordering interface; (2) clinician education, training, and monthly feedback; (3) team-based process redesign emphasizing accountability and safety culture; and (4) a subsequent system-level enhancement to the electronic ordering interface during a second PDSA cycle. The primary outcome was the rate of endometrial vs. endocervical mislabeling events per 1,000 orders. The researchers plotted time-series run charts and u-charts and calculated pre- and postintervention incidence rate ratios (IRRs).

Results

Among 42,968 curettings from January 2020 to May 2025, 46 endometrial/endocervical mislabeling events occurred. Mislabeling rates were 3.79 per 1,000 orders at baseline (9/2,373; January–May 2020), 3.80 between two PDSA cycles (33/8,683; June 2020–April 2021), and 0.13 following the second PDSA cycle (4/31,912; from May 2021), corresponding to a 96.7% reduction vs. baseline (IRR 0.03, 95% confidence interval [CI] 0.01–0.11, p < 0.001). Time-series charts showed a sustained special cause shift since May 2021, with 30 consecutive zero-error months between January 2022 and June 2024.

Conclusion

A combination of education, feedback, process audits, and interface redesign effectively addressed mislabeling of endometrial/endocervical specimens, a high-impact patient safety concern. This approach may be transferable to other LASA error domains.

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减少组织病理学标本的标记错误：KK妇幼医院子宫内膜与宫颈内膜标本的质量改进倡议，以促进患者安全。

背景：在新加坡KK妇女儿童医院的妇产科中，子宫内膜与宫颈内膜刮痧的错误标记是最常见的标本错误。这些外观相似/声音相似（LASA）错误可能会危及患者安全和工作流程效率。作者的目的是在两年的质量改进（QI）期间减少标本标记错误。方法：在进行根本原因分析后，采用计划-做-研究-行动（PDSA）方法在某三级妇产科中心开展多学科质量评价项目。在2020年至2022年期间，干预措施包括：(1)试点系统级增强电子订购界面；(2)临床医师教育、培训，每月反馈；(3)基于团队的流程重新设计，强调问责制和安全文化；(4)在第二个PDSA循环期间对电子订购接口的后续系统级增强。主要结局是每1000个订单中子宫内膜与宫颈内膜错误标记事件的发生率。研究人员绘制了时序运行图和u形图，并计算了干预前和干预后的发病率比（IRRs）。结果：在2020年1月至2025年5月的42,968例子宫内膜/宫颈内膜错误标记事件中，发生了46例。基线时（9/2,373；2020年1月至5月）的误标率为3.79 / 1,000个订单，两个PDSA周期之间（33/8,683；2020年6月至2021年4月）的误标率为3.80，第二个PDSA周期后（4/31,912；2021年5月）的误标率为0.13，与基线相比降低了96.7% （IRR 0.03, 95%置信区间[CI] 0.01-0.11, p < 0.001）。时间序列图显示，自2021年5月以来，特殊原因持续变化，2022年1月至2024年6月期间连续30个月为零误差。结论：教育、反馈、流程审核和界面重新设计的结合有效地解决了子宫内膜/宫颈内膜标本标签错误的问题，这是一个影响患者安全的问题。这种方法可以转移到其他LASA错误域。

本文章由计算机程序翻译，如有差异，请以英文原文为准。

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