Defining Errors and Error Reduction in Pathology Laboratory: Revisited
DEFINING ERRORS AND ERROR REDUCTION IN PATHOLOGY LABORATORY: REVISITED FELIPE S. TEMPLO, JR., MD DEPARTMENT OF PATHOLOGY & LABORATORY MEDICINE TAN TOCK SENG HOSPITAL SINGAPORE
PART I:DEFINING ERRORS IN ANATOMIC PATHOLOGYPART II:ERROR REDUCTION IN ANATOMIC PATHOLOGY
ERROR IN RELATION TO THE GOALS OF ANATOMIC PATHOLOGY GOAL OF ANATOMIC PATHOLOGY“TORENDER A CORRECT AND COMPLETE DIAGNOSISTO 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 competentpathologists will render similar results when observing or analyzing the same specimen.
ERROR IN RELATION TO THE GOALS OF ANATOMIC PATHOLOGYB. COMPLETE AND TIMELYConcepts: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 CYCLESPreanalytic phase of testing begins with the clinical encounter inwhich the specimen is obtained and ends with specimen receipt andaccessioning in the laboratory.Analytic phase pertains to those processes and steps that areperformed to analyze a specimen and to generate a report.Postanalytic phase encompasses those steps necessary tocommunicate the results in the analytic phase to the properclinicians so that the information can be used effectively in patientcare
ERRORS IN THEPREANALYTIC PHASE OF TESTING 1. Clinician errors 2. Transport phase 3. Receipt/Accessioning phase
ERRORS IN THEANALYTIC PHASE OF TESTING1. Histologic /cytologic errors2. Errors in the gross room3. Errors at the microscope4. Clerical errors during the generation of the report
ERRORS IN THEPOSTANALYTIC 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 input A. Incomplete or incorrect clinical history B. Incorrect or Improper patient identification 2. Complexity 1 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 ERRORS6. Time constraints - Batch work - Shortage of workers - Sudden increase in work loads7. Hierarchical culture
ERROR-REDUCTION STRATEGIES1. Reduce Reliance on Memory - proper usage of checklists2. Improve Information Access - electronic medical record3. Error-Proof Processes: Use Constraints and Forcing Functions -proper usage of computer
ERROR-REDUCTION STRATEGIES4. Decrease Reliance on Vigilance - quality control measures5. Standardize Tasks and Language6. Reduce the Number of Handoffs, Simplify the Process
ERROR-REDUCTION STRATEGIES7. Design for Error -case review8. Adjust the Work Schedule9. Adjust the Environment
ERROR-REDUCTION STRATEGIES10. Provide Adequate and Continuous Training11. Choose the Correct Staff for the Correct Job
ReferencesArchives 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