DEFINING ERRORS AND ERROR REDUCTION IN PATHOLOGY LABORATORY: REVISITED

FELIPE S. TEMPLO, JR., MDDEPARTMENT OF PATHOLOGY &

LABORATORY MEDICINE

TAN TOCK SENG HOSPITAL SINGAPORE

PART I:

DEFINING ERRORS IN ANATOMIC PATHOLOGY

PART II:

ERROR REDUCTION IN ANATOMIC PATHOLOGY

ERROR IN RELATION TO THE GOALS OF ANATOMIC PATHOLOGY

GOAL OF ANATOMIC PATHOLOGY

“TO RENDER A CORRECT AND COMPLETE DIAGNOSIS

TO THE CORRECT PATIENT IN A TIMELY FASHION IN A WAY THAT IS UNDERSTANDABLE AND USEFUL TO THE

PHYSICIAN TREATING THE PATIENT”

ERROR IN RELATION TO THE GOALS OF ANATOMIC PATHOLOGY

A. THE CORRECT DIAGNOSIS

Concepts:

1.Accuracy-few validated standards

2.Precision- usually implies that most competent pathologists will render similar results when observing or

analyzing the same specimen.

ERROR IN RELATION TO THE GOALS OF ANATOMIC PATHOLOGY

B. COMPLETE AND TIMELY

Concepts:

1. Checklist- College of American Pathologists

Royal College of Pathologists (UK)

2. Turn around time

DEFINING ERRORS IN ANATOMIC PATHOLOGY

A MAJOR error in anatomic pathology is an error that has a major effect on therapy that can alter the prognosis of a disease or that has a major effect on prognostication, exclusive of therapy.

A MINOR error is one that does not have a major effect on therapy that can alter prognosis or that does not have a major effect on prognostication, exclusive of therapy.

ANATOMIC PATHOLOGY ERRORS

THE TEST CYCLES

1. PREANALYTIC PAHSE

2. ANALYTIC PHASE

3. POSTANALYTIC PHASE

The TEST CYCLES

Preanalytic phase of testing begins with the clinical encounter in which the specimen is obtained and ends with specimen receipt and accessioning in the laboratory.

Analytic phase pertains to those processes and steps that are performed to analyze a specimen and to generate a report.

Postanalytic phase encompasses those steps necessary to communicate the results in the analytic phase to the proper clinicians so that the information can be used effectively in patient care

ERRORS IN THE PREANALYTIC PHASE OF TESTING

1. Clinician errors

2. Transport phase

3. Receipt/Accessioning phase

ERRORS IN THE ANALYTIC PHASE OF TESTING

1. Histologic /cytologic errors

2. Errors in the gross room

3. Errors at the microscope

4. Clerical errors during the generation of the report

ERRORS IN THE POSTANALYTIC PHASE OF TESTING

1. Errors to the delivery of report or information to the wrong clinician

2. Misunderstanding of the report

3. Failure of the caregiver to see the report.

FACTORS THAT CONTRIBUTE TO ERRORS

1. Variable inputA. Incomplete or incorrect clinical history

B. Incorrect or Improper patient identification

2. Complexity1 step: 1% error

25 steps: 22% error

3. Inconsistency

FACTORS THAT CONTRIBUTE TO ERRORS

4. Tight coupling

5. Human intervention- Machines perform very well with routine tasks, whereas

human perform best with unanticipated or unpredicted occurrences.

FACTORS THAT CONTRIBUTE TO ERRORS

6. Time constraints- Batch work- Shortage of workers- Sudden increase in work loads

7.  Hierarchical culture

ERROR-REDUCTION STRATEGIES 1. Reduce Reliance on Memory

- proper usage of checklists

2. Improve Information Access - electronic medical record

3. Error-Proof Processes: Use Constraints and Forcing Functions -proper usage of computer

ERROR-REDUCTION STRATEGIES

4. Decrease Reliance on Vigilance

- quality control measures

5. Standardize Tasks and Language

6. Reduce the Number of Handoffs,

Simplify the Process

ERROR-REDUCTION STRATEGIES

7. Design for Error

-case review

8. Adjust the Work Schedule

9. Adjust the Environment

ERROR-REDUCTION STRATEGIES

10. Provide Adequate and

Continuous Training

11. Choose the Correct Staff for the Correct Job

References

Archives of Pathology and Laboratory Medicine

1. February 2008, Vol. 132 No.2 pp. 181-185

2. May 2006, Vol 130 No.5 pp. 604-606

3. May 2006, Vol 130 No.5 pp. 630-632

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