We have resolved the issue by identifying that our EMR system, EPIC, was
not calculating the slides correctly. Due to this issue, we were utilizing an Excel spreadsheet to
manually calculate the slides for our SFS patients. This process did work and calculated the correct
slides as long as our front desk staff input the patient’s data correctly. In the instance of the samples
that had incorrect slides calculated, it appears that it was an user error where they must not have
adequately reviewed the patient’s information and entered it correctly into the spreadsheet. Our corrective action plan is that we are no longer going to use
the spreadsheet for calculating SFS slides for our patients. This will be done in EPIC now that it is able
to correctly calculate the slides. We will continue to use our internal trainer to work with the front desk
staff to ensure they understand how to review the SFS applications and supporting documentation, as
well as enter the patient data into EPIC to calculate the correct slides. Furthermore, each clinic
manager will review the SFS applications on a daily basis to verify the correct slides were calculated for
each patient.