Reducing Errors in Radiology Specimen Labeling Through Use of a Two-person Check.

Improper specimen labeling of biopsy samples can cause substantial harm to patients through diagnostic delays, administration of inappropriate treatments, and can result in a loss of trust in the healthcare system. Specimen labeling errors are considered a relevant safety metric in our department and tracked on a rolling basis. One imaging section was noted to have nearly completely eliminated these errors through implementation of a 2-person check prior to submission to pathology. The purpose of this intervention was to identify the causes of continued specimen labeling errors in radiology and to standardize the specimen labeling workflow across the department of radiology to include the best practice identified in breast imaging utilizing a 2-person check. Preintervention, 31 specimen labeling errors were reported by the procedural staff over a period of 149 weeks resulting in an error rate of 0.21 errors per week. Postintervention, 3 specimen labeling errors occurred in the next 46 weeks resulting in a rate of 0.07 errors per week, a 68.8% decrease in the specimen labeling error rate. This quality improvement project highlights the process flaws which contribute to medical errors and demonstrates a potential pathway to try and reduce these errors and patient harm without significant investment in capital or new technology.

Patient-Awareness Survey: Do Breast Implants Affect the Acquisition and Accuracy of Screening Mammography?

OBJECTIVE: Breast implant augmentation is the most common cosmetic surgical procedure performed in the United States. The purpose of this study was to determine if patients with breast augmentation surgery are aware of the effect of breast implants on the mammographic detection of cancer. METHODS: An institutional review board exempt patient awareness survey was distributed at a single breast imaging facility to women undergoing screening mammography. Comparative statistical analyses were performed between patients with and without breast implants. RESULTS: The respondents were divided into three groups: no prior breast surgery (74%; 524/711), breast surgery with implants (21%; 152/711), and breast surgery without implants (5%; 35/711). Patients with breast implants were more aware that implants decrease the amount of breast tissue seen on a mammogram (75%; 105/141) and that implants result in the need for more mammogram views (70%; 103/147), as compared with patients with no surgery (46%; 221/484 and 31%; 147/478, respectively) (P < 0.001). More women with breast implants reported learning from breast imaging staff rather than from their surgeon that implants decrease the amount of breast tissue seen on a mammogram (46%; 49/106 vs. 38%; 40/106). Of 137 respondents, 35% (n = 48) reported that the effect of implants on their mammogram was discussed preoperatively. Of those who did not recall a preoperative discussion, 42% (16/38) indicated this knowledge would have factored into their decision to get breast implants. CONCLUSION: This study highlights an opportunity for providers to engage in more education and shared decision-making with patients considering breast augmentation surgery to ensure preoperative counseling includes discussion of the effect of implants on mammography.