Problem | Solution | Driver | Type | Outcome | Success | Complexity | Failure |
Blocks needing re-infiltration are placed in back room and forgotten | Create visual cue reminder | Q | A | 2.5 | 4 | 1 | 6 |
Initial H&E time delay due to main cutter cutting special stains | Introduce second cutter to line | T | C | 3.5 | 4 | 2 | 1 |
Histotechnologists spend too much time attending medical kidney procedure | Histotechnologists no longer attend procedure | T | P | 3.25 | 4 | 4 | 2 |
Materials (eg, slides in trays) left in labeller without defined purpose creating confusion | Purchased multibin units to define purpose of each bin (eg, deeper levels) | T | C | 3.25 | 5 | 2 | 3 |
Ambiguity in Saturday work prioritisation | Create checklist to Saturday workflow | Q | A | 2.5 | 3 | 1 | 1 |
Elimination of pathology information as a result of new hospital information system | Creation of new informatics tools to handle loss of information | T | C | 3.25 | 5 | 5 | 4 |
Difficult to track kit inventory requirements for special stain bench | Institute kanban card inventory replenishment system | C | A | 2.0 | 3 | 2 | 2 |
Driver: Q, quality; C, cost; T, time.
Type of intervention: S, system; P, pathway; C, connection; A, activity.
Failure, number of specific errors addressed (Box 2).