Date of Graduation

Fall 12-11-2020

Document Access

Restricted Project/Capstone - USF access only

Degree Name

Master of Science in Nursing (MSN)


School of Nursing and Health Professions


As organizations strive towards achieving high reliability in healthcare, an outpatient Dermatology Department aims to improve the quality and patient safety within its microsystem by addressing the most common errors encountered in dermatology practices. The Dermatology Department provides care to an average of 200-280 patients per day and collects an average of 950 biopsy specimens per month. According to pathology data tracking, approximately 1.41% of the specimens collected by the Dermatology Department have been rejected due to errors in the past 24 months. Generally, system failures that lead to these types of errors can have serious implications to patients and providers and result in significant harm to the patient, institution and distrust by community (Makary et al., 2007). Thus, addressing specimen handling errors by incorporating failure-free systems becomes a top priority, as it is the most common error in the Dermatology Department microsystem. Using the Model of Improvement and Lippitt’s Change Theory, we will implement two safety protocols: a biopsy timeout to enhance communication and a specimen handling log as a double-check method during the pre-analytic phase of specimen handling. The results will be measured using outcome and process measures. The proposed improvement project is expected to improve patient safety in the Dermatology Department as evidenced by 100% reliability in specimen handling process by December 1, 2020.

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