This document discusses errors in pathology laboratories and strategies for reducing errors. It defines major errors as those that can alter prognosis or therapy, while minor errors do not. Errors can occur in the pre-analytic, analytic, and post-analytic phases of testing. Factors that contribute to errors include variable input, complexity, inconsistency, time constraints, and hierarchical cultures. Strategies for reducing errors include using checklists, electronic medical records, standardized processes, quality control, reducing handoffs, task simplification, case reviews, training, and choosing the right staff.

1. DEFINING ERRORS AND ERROR
REDUCTION IN PATHOLOGY
LABORATORY: REVISITED
FELIPE S. TEMPLO, JR., MD
DEPARTMENT OF PATHOLOGY &
LABORATORY MEDICINE
TAN TOCK SENG HOSPITAL SINGAPORE

2. PART I:
DEFINING ERRORS IN ANATOMIC PATHOLOGY
PART II:
ERROR REDUCTION IN ANATOMIC PATHOLOGY

3. ERROR IN RELATION TO THE GOALS OF
ANATOMIC PATHOLOGY
GOAL OF ANATOMIC PATHOLOGY
“TORENDER 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”

4. 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.

5. 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

6. 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.

7. ANATOMIC PATHOLOGY ERRORS
THE TEST CYCLES
1. PREANALYTIC PAHSE
2. ANALYTIC PHASE
3. POSTANALYTIC PHASE

8. 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

9. ERRORS IN THE
PREANALYTIC PHASE OF TESTING
1. Clinician errors
2. Transport phase
3. Receipt/Accessioning phase

10. 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

11. 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.

12. 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

13. 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.

14. FACTORS THAT CONTRIBUTE TO ERRORS
6. Time constraints
- Batch work
- Shortage of workers
- Sudden increase in work loads
7. Hierarchical culture

15. 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

16. 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

17. ERROR-REDUCTION STRATEGIES
7. Design for Error
-case review
8. Adjust the Work Schedule
9. Adjust the Environment

18. ERROR-REDUCTION STRATEGIES
10. Provide Adequate and
Continuous Training
11. Choose the Correct Staff for the
Correct Job

19. 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

20. THANK YOU