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The effect of a Lean quality improvement implementation program on surgical pathology specimen accessioning and gross preparation error frequency.
September 1, 2012
Smith ML, Wilkerson T, Grzybicki DM, et al. Am J Clin Pathol. 2012;138(3):367-373.
Entering pathology test results into the wrong patient’s record but discovering the error before the results are released is a type of pathology near miss. Using Lean quality improvement program (LQIP), including culture change, one anatomic pathology laboratory sought to reduce both process- and operator-dependent near-miss events. The laboratory was able to decrease the frequency of process-dependent near-miss events, though not the operator-dependent events. The authors cite lack of leadership buy-in as a major challenge.
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