Error Reduction and Prevention in Surgical Pathology PDF
Preview Error Reduction and Prevention in Surgical Pathology
Error Reduction and Prevention in Surgical Pathology Raouf E. Nakhleh Editor Error Reduction and Prevention in Surgical Pathology 1 3 Editor Raouf E. Nakhleh Pathology Mayo Clinic Florida Jacksonville Florida USA ISBN 978-1-4939-2338-0 ISBN 978-1-4939-2339-7 (eBook) DOI 10.1007/978-1-4939-2339-7 Library of Congress Control Number: 2014960069 Springer Cham Heidelberg New York Dordrecht London © Springer Science+Business Media New York 2015 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, express or implied, with respect to the material contained herein or for any errors or omissions that may have been made. Printed on acid-free paper Springer is part of Springer Science + Business Media (www.springer.com) Contents 1 Introduction ................................................................................................ 1 Raouf E. Nakhleh 2 The Landscape of Error in Surgical Pathology ....................................... 3 Frederick A. Meier 3 General Principles of How Errors Occur and How They May Be Reduced ........................................................................................ 27 Maxwell L. Smith and Stephen S. Raab Part I Pre-Analytic Factors Contributing to Errors and Error Prevention 4 Error Reduction in the Preanalytical Process ......................................... 43 Richard W. Brown 5 A pplication of Lean Principles to Preanalytic and Analytic Processes ............................................................................... 59 Anil Vasdev Parwani, Seung Lyung Park and Liron Pantanowitz Part II Analytic Factors Contributing to Errors and Error Prevention 6 Clinical History and Clinical Correlation ................................................ 85 Keith E. Volmar 7 Knowledge, Training, and Experience ..................................................... 103 Amelia Huck and Vania Nosé 8 S tandardization of Diagnostic Terminology and Criteria: A Prelude for Error Reduction ..................................................................... 115 Raouf E. Nakhleh v vi Contents 9 Ancillary Studies: Contribution to Error and Error Prevention .......... 127 Paul E. Swanson 10 Optimization of Case Reviews in Different Practice Settings ................ 149 Raouf E. Nakhleh Part III Post-analytic Factors Leading to Errors and Error Prevention 11 The Complete Surgical Pathology Report ............................................... 163 Michael O. Idowu 12 Communicating Effectively in Surgical Pathology ................................. 185 Carolyn Mies 13 Error Prevention in Transcription and Report Distribution ................. 197 Shannon J. McCall 14 Error Management: Legal and Regulatory Responsibilities ................. 209 Timothy Craig Allen Index .................................................................................................................. 221 Contributors Timothy Craig Allen Department of Pathology, The University of Texas Medical Branch, Galveston, TX, USA Richard W Brown System Laboratory Services, Memorial Hermann Healthcare System, Houston, TX, USA Amelia Huck Department of Pathology, Massachusetts General Hospital, Boston, MA, USA Michael O. Idowu Department of Pathology, Virginia Commonwealth University Health System, Richmond, VA, USA Shannon J. McCall Department of Pathology, Duke University, Durham, NC, USA Frederick A. Meier Department of Pathology and Laboratory Medicine, Henry Ford Hospital, Detroit, MI, USA Department of Pathology, School of Medicine, Wayne State University, Detroit, MI, USA Carolyn Mies Division of Anatomic Pathology, Department of Pathology & Laboratory Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA Raouf E. Nakhleh Department of Pathology, Mayo Clinic Florida, Jacksonville, FL, USA Vania Nosé Anatomic and Molecular Pathology, Massachusetts General Hospital, Boston, MA, USA Liron Pantanowitz Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA Seung Lyung Park Department of Pathology, University of Alabama in Birmingham, Birmingham, AL, USA vii viii Contributors Anil Vasdev Parwani Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA Stephen S. Raab Department of Laboratory Medicine, University of Washington and Memorial University of Newfoundland, Seattle, WA, USA Maxwell L. Smith Department of Laboratory Medicine and Pathology, Mayo Clinic Arizona, Scottsdale, AZ, USA Paul E. Swanson Cumming School of Medicine, University of Calgary, Pathology and Laboratory Medicine Calgary Laboratory Services, Foothills Medical Centre, Calgary, AB, Canada Keith E. Volmar Rex Pathology Associates, Raleigh, NC, USA Chapter 1 Introduction Raouf E. Nakhleh Introduction As surgical pathologists, we are excited by every case that comes before us because AQ1 of the opportunity to make a diagnosis that matters to patients and clinicians. A correct diagnosis sets the patient and clinician along an appropriate treatment path. At the same time, there is an understanding that surgical pathology processes and laboratories are complex systems that offer ample opportunity to make mistakes. Errors occur for a variety of reasons. Some occur because of poor processes, some occur because of a lack of knowledge, some occur due to carelessness, and some occur because of external stresses. Trying to evaluate every possible source of error can be daunting. By breaking down the system into segments and evaluating each segment, errors can be more easily classified, analyzed, and addressed. Surgical pathology is a laboratory discipline of testing that has a defined test cycle of preanalytic, analytic, and postanalytic. Preanalytic and postanalytic chal- lenges of specimen identification and processing as well as report generation and delivery are similar to processes that occur in clinical laboratories. The specimens in surgical pathology are unique and many times cannot be obtained a second time as can be done with blood or urine specimens. The procedures to obtain surgical pathology specimens are also far more complex making it unpalatable to lose, mis- label, or mishandle a specimen. In this book, we include two chapters addressing the preanalytic phase of the test cycle including specimen identification, specimen handling, and the use of lean methodology to reduce errors in specimen process- ing. Three chapters are included to address the postanalytic phase of the test cycle including the complete surgical pathology report, communication of the results, and error reduction in transcription and report delivery. Also, unique to surgical pathology is that the analytic phase of the test cycle is largely depended on pathologists’ cognitive ability to interpret visual evidence R. E. Nakhleh () Department of Pathology, Mayo Clinic Florida, 4500 San Pablo Rd., Jacksonville, FL 32224, USA e-mail: [email protected] © Springer Science+Business Media New York 2015 1 R. E. Nakhleh (ed.), Error Reduction and Prevention in Surgical Pathology, DOI 10.1007/978-1-4939-2339-7_1 2 R. E. Nakhleh and recognize disease. This adds to the complexity of the process but also offers potential solutions. It is the author’s belief that the analytic phase of the test cycle is dependent on five factors, each to be addressed in a chapter: 1. The pathologist’s knowledge, experience, and training, 2. Clinical correlation, 3. Use of ancillary confirmatory testing, 4. Use of standardized criteria for diagnosis and reporting standardized elements, and 5. Selectively reviewing cases to assure accuracy. In this book, we have attempted to describe aspects of practice that lead to error as well as define practices that avoid error. The book is organized to address each of the phases of the test cycle (preanalytic, analytic, and postanalytic), as well as how to deal with errors when they occur. In addition, there is a chapter that addresses how often and where in the test cycle errors occur as well as a chapter that discusses general principles of error reduction. This latter chapter examines what has been learned in other industries and the science of process optimization and error reduc- tion. The final two chapters discuss the legal ramification of errors and possible actions to try and minimize deleterious effects of surgical pathology errors. Medicine has changed a great deal in the past few decades. Public perception of physicians has also changed a great deal. Fifty years ago, physicians were highly re- garded professionals who could do no wrong. Today, the lay media has depicted nu- merous examples of medical errors leading to patient harm, and the public is weary and sensitive to any suggestion of error in their healthcare. At the same time, we must have the realization that errors will occur; after all, we are all human and are fallible and prone to error. In this book, we try to systematically examine sources of error and offer what has been learned to avoid these errors. Our current systems are far from perfect, but there is evidence that we are inching forward with improve- ment and reduction of error.
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