Error Awareness

Vol. 24 • Issue 9 • Page 10


In the past, the hospital laboratory was considered the hub of the wheel from which all spokes of good patient care revolved. The modern laboratory claiming the title as the “hub of the hospital” must be organized with meticulous care and devoted to precise diagnoses. Ultimately, the precise diagnoses generated may be rendered useless or even dangerous if not directed to the correct patient.

Recently, an international group of experts in the field of anatomic pathology from academic, private and governmental institutions participated in an endeavor to evaluate patient care. Each shared a direct involvement in discussions regarding laboratory organization and promotion of patient safety practices. This group convened to address the current status of patient safety and the current role of an anatomic pathology lab, as well as future trends in patient safety, with the aim of determining best approaches to improving quality and patient safety as a standard of care. The group developed and publicized its “Four Key Principles for Pathology and Patient Safety:”

1. Global standardization for pathology services – All patients around the globe deserve standardized, high quality pathology services

2. Improve laboratory processes – Opportunities exist to improve patient safety by developing and implementing solutions to enhance:

  • Tissue preservation
  • Specimen/slide identification and tracking
  • Prevention of tissue contamination

3. Initiate standardized data collection and sharing – Opportunity exists to advance quality measures in the laboratory with standardized parameters for data collection and sharing.

4. Implement communication channels with others involved in patient care – Pathology professionals should collaborate with laboratory and hospital administrative partners, clinician colleagues and the laboratory diagnostics industry to identify opportunities and implement changes to achieve excellence in patient care.

As a consequence of these initial discussions, a broader patient-safety initiative has been established with the following goals:

• Increase awareness and broaden the dialogue among stakeholders outside the laboratory setting.

• Establish validated quality metrics.

• Gather real error rate data from laboratories.

• Develop a framework to help prevent errors in the lab.

Patient safety errors are under-recognized and under-reported. Accreditation agencies enforce stringent quality testing; however, a similar workflow does not exist for standardization of documenting and investigating patient safety incidents. Shane Kohl, MD, of Nebraska Methodist Health System, stated, “The importance of patient safety within the anatomic pathology laboratory cannot be overemphasized, since diagnoses made from tissue specimens have huge implications in the management and care of patients. It is crucial that, from the time of tissue procurement to the rendering of a diagnosis within a pathology report, that all parties involved with patient tissue specimens be aware and actively participate in the safe handling of those specimens to best prevent events that may lead to less optimal or inaccurate results.” It is critical to gather and document error data unanimously even when unfavorable outcomes occur, to improve patient care.

The patient safety initiative resulted in a comprehensive list of anatomic pathology quality metrics related to patient safety issues. Error data is collectively gathered from independent offices to large reference labs, to ensure that patient safety indicators are captured, in a consistent manner. These metrics range from specimen accessioning, grossing, preparation and labeling of cassettes and slides to ordering and performance of tissue stains. The recommended metrics will be shared through peer-reviewed publications in professional journals, ensuring awareness is communicated to all stakeholders in the laboratory (i.e., medical technologists, histotechnologists, cytotechnologists, pathologist assistants and pathologists). Ultimately, the recommendation is for all anatomic pathology laboratories to implement a program to document and monitor the high priority metrics. Transparency across all key stakeholders in the anatomic pathology laboratory will drive awareness of the importance of patient safety.

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