Diagnostic Histopathology
Volume 14, Issue 7 , Pages 292-298 , July 2008

Safety practices in surgical pathology: practical steps to reduce error in the pre-analytic, analytic, and post-analytic phases of surgical pathology

References 

  1. Nakhleh RE. Patient safety and error reduction in surgical pathology. Arch Pathol Lab Med. 2008;132:181–185
  2. Linker JK. The Toyota Way: 14 management principles from the world’s greatest manufacturer. New York: McGraw Hill; 2004;
  3. Condel JL, Sharbaugh DT, Rabb SS. Error-free pathology: applying lean production methods to anatomic pathology. Clin Lab Med. 2004;24:865–899
  4. Zarbo RJ, D’Angelo R. The Henry Ford production system: effective reduction of process defects and waste in surgical pathology. Am J Clin Pathol. 2007;128:1015–1022
  5. D’Angelo R, Zarbo RJ. The Henry Ford production system: measures of process defects and waste in surgical pathology as a basis for quality improvements in surgical pathology. Am J Clin Pathol. 2007;128:423–429
  6. Nevalainen DE, Berte L, Kraft C, et al. Evaluating laboratory performance on quality indicators with the six sigma scale. Arch Pathol Lab Med. 2000;124:516–519
  7. Brown RW. Quality management in the laboratory. In:  Nakhleh RE,  Fitzgibbons PL editor. Quality management in anatomic pathology: promoting patient safety through systems improvement and error reduction. Northfield, Illinois: College of American Pathologists; 2005;p. 77–92
  8. Valenstein PV, Schneider F. Benchmarking laboratory quality. Lab Med. 2008;39:108–112
  9. Raab SS, Jones BJ, Souers R, et al. The effect of continuous monitoring of cytologic-histologic correlation data on cervical cancer screening performance. Arch Pathol Lab Med. 2008;132:16–22
  10. Raab SS, Tworek JA, Souers R, et al. The value of monitoring frozen section–permanent section correlation data over time. Arch Pathol Lab Med. 2006;130:337–342
  11. Bekeris LG, Tworek JA, Walsh MK, et al. Trends in blood culture contamination: a College of American Pathologists Q-tracks study of 356 institutions. Arch Pathol Lab Med. 2005;129:1222–1225
  12. Nakhleh RE, Zarbo RJ. Surgical pathology specimen identification and accessioning: a College of American Pathologists Q-probes study of 1004115 cases form 417 institutions. Arch Pathol Lab Med. 1996;120:227–233
  13. Nakhleh RE, Gephardt G, Zarbo RJ. Necessity of clinical information in surgical pathology: a College of American Pathologists Q-probes study of 771475 surgical pathology cases form 341 institutions. Arch Pathol Lab Med. 1999;123:615–619
  14. Troxell DB, Sabella JD. Problem areas in pathology practice: uncovered by review of malpractice claims. Am J Surg Pathol. 1994;18:821–831
  15. Gephardt GN, Zarbo RJ. Extraneoous tissue in surgical pathology: A College of American Pathologists Q-probes study in 275 laboratories. Arch Pathol Lab Med. 1996;120:1009–1014
  16. Renshaw AA, Kish R, Gould EW. The value of inking breast cores to reduce specimen mix-up. Am J Clin Pathol. 2007;127:271–272
  17. Slavin L, Best MA, Aron DC. Gone but not forgotten: the search for the lost surgical specimens: application of quality improvement techniques in reducing medical errors. Qual Manag Health Care. 2001;10:45–53
  18. Nakhleh RE. Lost, mislabeled and unsuitable surgical pathology specimens. Pathol Case Rev. 2003;8:98–102
  19. Association of Directors of Anatomic and Surgical Pathology . Recommendations on quality control and quality assurance in surgical pathology and autopsy pathology. Am J Surg Pathol. 1991;15:1007–1009
  20. Safrin RE, Bark CJ. Surgical pathology signout: routine review of every case by a second pathologist. Am J Surg Pathol. 1993;17:1190–1192
  21. Whitehead ME, Fitzwater JE, Lindley SK, et al. Quality assurance of histopathology diagnoses: a prospective audit of three thousand cases. Am J Clin Pathol. 1984;81:487–491
  22. Renshaw AA, Gould EW. Measuring errors in surgical pathology in real-life practice: defining what does and does not matter. Am J Clin Pathol. 2007;127:144–152
  23. Renshaw AA, Gould EW. Comparison of disagreement and amendment rates by tissue type and diagnosis: identifying cases for directed blinded review. Am J Clin Pathol. 2006;126:736–739
  24. Nakhleh RE, Zarbo RJ. Amended reports in surgical pathology and implications for diagnostic error detection and avoidance. Arch Pathol Lab Med. 1998;122:303–309
  25. Renshaw AA, Pinnar NE, Jiroutek MR, Young ML. Quantifying the value of in-house consultation in surgical pathology. Am J Clin Pathol. 2002;117:751–754
  26. Renshaw AA, Gould EW. Correlation of workload with disagreement and amendment rates in surgical pathology and nongynecologic cytology. Am J Clin Pathol. 2006;125:820–822
  27. Raab SS, Grzybicki DM. Anatomic pathology workload and error. Am J Clin Pathol. 2006;125:809–812
  28. Vollmer RT. Regarding workload and error rates in anatomic pathology. Am J Clin Pathol. 2006;126:833
  29. Raab SS, Grzybicki DM, Sudilovsky D, et al. Effectiveness of Toyota Process redesign in reducing thyroid gland fine-needle aspiration error. Am J Clin Pathol. 2006;126:585–592
  30. Powsner SM, Costa J, Homer RJ. Clinicians are from Mars and pathologists are from Venus: Clinician interpretation of pathology reports. Arch Pathol Lab Med. 2000;124:1040–1046
  31. College of American Surgeons . Commission on Cancer of the College of American Surgeons cancer program standards. Standard 4.6: the guidelines for patient management and treatment currently required by the CoC. Available from: www.facs.org/cancer/coc/cocprogramstandards.pdf2008;(accessed 24.02.08)
  32. College of American Pathologists . Cancer protocols and checklists. Available from: www.cap.org/apps/docs/cancer_protocols/protocols_index.html2008;(accessed 24.02.08)
  33. Branston LK, Greening S, Newcombe RG, et al. The implementation of guidelines and computerized forms improves the completeness of cancer pathology reporting. The CROPS project: a randomized controlled trial in pathology. Eur J Cancer. 2002;38:764–772
  34. Valenstein PN. Formatting pathology reports: applying four design principles to improve communication and patient safety. Arch Pathol Lab Med. 2008;132:84–94
  35. Association of Directors of Anatomic and Surgical Pathology . Critical diagnoses (critical values) in anatomic pathology. Am J Surg Pathol. 2006;30:897–899

PII: S1756-2317(08)00087-X

doi: 10.1016/j.mpdhp.2008.06.002

Diagnostic Histopathology
Volume 14, Issue 7 , Pages 292-298 , July 2008