Frozen-Section Checklist Implementation Improves Quality and Patient Safety

Yigu Chen, MPH; Kevin R. Anderson, MD, PhD; Jia Xu, MD; Jeffrey D. Goldsmith, MD; Yael K. Heher, MD, MPH


Am J Clin Pathol. 2019;151(6):607-612. 

In This Article


Labeling Accuracy

Prior to implementation of the IOC checklist, we found that the majority (85%, 481) of frozen-section cases had slides that had defects in at least one patient identifier Figure 2. Overall, 27% (74) of postintervention cases had slides missing at least one patient identifier, including 24% (65) missing the specimen location designation, 15% (41) missing the patient's MRN, and 8% (23) missing the patient's name. Implementation of an IOC checklist resulted in the reduction of labeling defects for cases missing at least one identifier, cases missing specimen location designation, cases missing the patient's MRN, and cases missing the patient's name by 68%, 71%, 62%, and 65%, respectively, which were all statistically significant reductions in defects (P < .001).

Figure 2.

Intraoperative consultation labeling defect rates and turnaround time by month.


We were able to obtain TAT data for 521 preintervention cases from the previous frozen-section worksheets. IOCs were self-reported as taking an average of 21.6 minutes before checklist implementation, interestingly, with 55% of the cases self-reported as an exact TAT of either 15 or 20 minutes. TAT data were examined for 204 postintervention cases. Average TAT per case was approximately 1.6 minutes longer compared with the preintervention period, but the difference was not statistically significant (P = .071). Percentage of reported TATs of either exactly 15 or 20 minutes was decreased to 35% during the postintervention period, and TAT data were more normally distributed (Table 1 and Table 2).