GME Patient Safety Quality and Innovation Symposium

Background: Resident-run minor surgery clinics have been shown to increase operative autonomy experience for trainees, while delivering high-quality patient care. However, at least 3 mislabeled lab specimens were reported from the resident-run San Diego VAMC minor surgery clinic from May 2025-November 2025, with 47 mislabeling events total across our institution. A root cause analysis (RCA) investigating institution-wide specimen mislabeling identified a lack of standardized clinic processes as a source of mislabeling errors. We aimed to standardize the minor surgery clinic process by implementing pre- and post-operative checklists, including a double verification of accurate specimen labeling, with a goal of residents recording 75% compliance over 4 months. 

Methods: A Gemba walk was performed of the General Surgery Minor Procedures Clinic at the San Diego VAMC, where small soft tissue mass excisions (e.g. lipomas) are performed by residents on veterans. A single clinic nurse is present for each appointment. There is minimal attending supervision to maximize resident autonomy. Using Lean theory (Figure 1), we identified muri, or overburden, as the potential source of error, as residents must develop their own processes in clinic to remember all key elements of pre- and post-operative veteran care, including submission of an anatomic pathology consult order that exactly matches the labeled specimen cup. The RCA identified checklists and double verification of accurate specimen labeling matching pathology consult orders as a strong measure to reduce errors and improve reliability. Pre- and post-operative checklists, modeled after the pre-operative huddle and post-operative debrief performed in the operating rooms, were piloted in clinic in November 2025. Procedure note templates for residents were created for residents to self-indicate whether the checklists and double verification were performed or not, with chart reviews performed weekly starting January 2026 to monitor recording of compliance. Risk management updated the team with any new JPSR for mislabeled specimens from the General Surgery Minor Procedures Clinic. Residents also completed Redhatch Consulting, Ltd., System Usability Scale (SUS) surveys that were modified to evaluate the checklists' ease-of-use. 

Results: Since implementation of checklists from January 2026-April 2026, there were 86 minor procedures performed in which specimens were collected. Performance of checklists and double verification of specimen labeling were recorded in 81% of procedures (70/86). There were 2 mislabeled lab specimens: 1 date was mislabeled and 1 cup letter was mislabeled. SUS surveys of 5 residents reported an average usability score of 99 out of 100, suggesting the checklists were easy to learn and use, with minimal disruption to clinic flow. These quantitative results were reflected in associated interviews with residents at the end of service (see Table for residents' responses). 

Discussion: Pre- and post-operative checklists were easy to use and reduced specimen mislabeling with over 75% recorded compliance by residents by standardizing clinic processes for overburdened residents, especially interns. We aim to have more surgical specialty clinics adopt similar checklists. Further careful adaptation will be needed to implement these changes in institution-wide, such as in the emergency department.