General Principles of How Errors Occur and How They May Be Reduced
Fig. 3.1 The Swiss Cheese Model of error causation. Each slice of cheese represents a step in the health care process. The “holes” represent errors in each individual step, either…
PATHOLOGY & LABORATORY MEDICINE
The Landscape of Error in Surgical Pathology
Fig. 2.1 A twelve-step program: surgical pathology as a production process Amended Reports and practical errors: Amended reports in surgical pathology are like accident reports . As sources for a…
Error Management: Legal and Regulatory Responsibilities
53. Kapp MB. Medical error versus malpractice. DePaul J Health Care L. 1997;1:751–72. 54. Blum JD. Regulating for patient safety: the law’s response to medical errors: article: combating those ugly…
Error Prevention in Transcription and Report Distribution
© Springer Science+Business Media New York 2015Raouf E. Nakhleh (ed.)Error Reduction and Prevention in Surgical Pathology10.1007/978-1-4939-2339-7_13 13. Error Prevention in Transcription and Report Distribution Shannon J. McCall1 (1) Department of Pathology, Duke University, 327C Davison…
Communicating Effectively in Surgical Pathology
© Springer Science+Business Media New York 2015Raouf E. Nakhleh (ed.)Error Reduction and Prevention in Surgical Pathology10.1007/978-1-4939-2339-7_12 12. Communicating Effectively in Surgical Pathology Carolyn Mies1 (1) Division of Anatomic Pathology, Department of Pathology & Laboratory Medicine,…
Optimization of Case Reviews in Different Practice Settings
Review type Explanation of process Targeted Review of specific types of cases either by diagnosis or by organ system Random Review of cases using a previously outline method of selecting…
Ancillary Studies: Contribution to Error and Error Prevention
Element Risk Mitigation Antibody–epitope specificity Cross-reactivity (shared epitopes) and neoepitopes False or unexpected positives Be aware of expected antibody specificity and reported patterns of “unexpected” staining; repeat tests with unexplained…
Standardization of Diagnostic Terminology and Criteria: A Prelude for Error Reduction
Necessary features Demonstration Ease of use Ease of use in all settings, not just tertiary centers; the process should be simple Reproducibility Sufficient studies demonstrating good diagnostic agreement with moderate…
Knowledge, Training, and Experience
Specialty Reviewed cases Major Minor Major discrepancy rate Breast 29 3 5 0.10 Bone and soft tissue 13 3 2 0.23 Cytology 2 1a 0 0.50 Dermatopathology 5 2 0…
Introduction
© Springer Science+Business Media New York 2015Raouf E. Nakhleh (ed.)Error Reduction and Prevention in Surgical Pathology10.1007/978-1-4939-2339-7_1 1. Introduction Raouf E. Nakhleh1 (1) Department of Pathology, Mayo Clinic Florida, 4500 San Pablo Rd., Jacksonville, FL 32224, USA…
