Tissue Tracking Study

¶ … reformation of the tissue tracking process, after conducting a literature review of current standard operating procedures regarding tissue labeling and screening, the proposed intervention was implemented. The pre-intervention practice involved the clinician immediately putting the tracking information regarding the implants in a log book. Every clinician was assigned a book to ensure immediate recording of the data (this involved three log books, one per clinician).

When the implants were needed, nurses logged the use by going to the corresponding log book, finding where the clinician logged it in, and placing a patient sticker identifying which patient had been assigned the tissue. The, the nurse would fill in the rest of the tracking information. This system, as might be expected, this was extremely cumbersome and inefficient for the nurses. Since three log books were used, there were frequent errors.

Log books were often lost, stickers were not placed correctly, and the tracking information was recorded, particularly when nurses were overburdened. And, perhaps worst of all, there was no accountability regarding the process, either. If one nurse made an error she could very easily blame another and if someone lost a log book, there was no way to trace the loss to the individual. The post-intervention practice change involved a reformation of the tracking procedure.

Once the implants arrived, nurses would use a generic sticker form that was 1/3 the landscape size of a standard piece of paper to immediately fill in implant information. The stickers were placed in a single log book under the care of a single nurse. When the nurses used an implant, they would fill out one of the new forms that are 2/3 of a landscape standard piece of paper. These forms were generic and placed at each place the biological implants were stored for easy access for nurses.

Once the form was filled out, the nurses would place it in a mailbox next to where they place other paperwork for the case. Every Friday nights, the forms were reviewed and matched with the corresponding stickers, completing the paper trail from shipment receiving to use. As well as reforming the standard operating procedures and engaging in such review, a comparison was conducted of errors pre and post-change.

During the pre-change phase, ten tissues had been failed to be tracked but post-change this was only two, indicating significant improvement after the shift. However, two is still too many, given that the goal of the study was zero defects. Limitations In terms of the implications for other practices, there are certain limitations to this study, most notably the fact that it is focused upon a single practice setting and involved a relatively limited number of tracked items. Also, the goals of the study were not fully realized.

Errors were still manifest after the intervention. Given the profound health consequences errors can have, this remains unacceptable. It did appear that downsizing the amount of books out in circulation to zero reduced the chances of lost books and the process was more streamlined and the predetermined forms ensured that nurses recorded comprehensive information. However, given the short duration of the study, it was not clear if this was due to the change in policy or to other factors.

Also, there were some problems when there were no forms and stickers and the fact that there was no failsafe backup if a nurse made an error filling out the data. A longer study would be required to fully note and track the degree of severity of the problem. It is not clear if the errors were due to an eccentric 'one off' issue or if they were pervasive.

Conclusions and recommendations for future research The system remains a work in progress and a study of longer duration would be needed to see if the continued observation was viewed over time. Also, based upon this preliminary research, an even more streamlined process would be ideal, since information was still lost. There was also insufficient fail-safe procedures to ensure that mistakes were caught immediately, and not after the fact. A substantial reduction in errors was noted but it still did not meet the zero defect goals of the study.

Tissues were still not charted or misplaced. A further consideration is human error. Given the weighty responsibilities assumed by nurses during the study, improved training in tracking and following standard operation procedures (including underlining the seriousness of standard operating procedures) might be needed for positive reforms to take hold in practice. A zero defect practice culture must be created and a further study identifying positive training techniques might also be valuable.

Again, the persistence of error might be attributed to the relatively novel nature of the reforms and a more extensive longitudinal study.