Pathology and patient safety: the critical role of pathology informatics in error reduction and quality initiatives.

Michael J Becich; John R Gilbertson; Dilipkumar Gupta; Ashokkumar Patel; Dana Marie Grzybicki; Stephen S Raab

Review

Pathology and patient safety: the critical role of pathology informatics in error reduction and quality initiatives.

March 6, 2005

Becich MJ, Gilbertson JR, Gupta D, et al. Clin Lab Med. 2004;24(4):913-43, vi.

View more articles from the same authors.

This article reviews patient safety concepts and describes how pathology informatics can help prevent errors.

PubMed citation

Available at

Related Resources From the Same Author(s)

Database construction for improving patient safety by examining pathology errors.

September 28, 2005

Effectiveness of Toyota process redesign in reducing thyroid gland fine-needle aspiration error.

October 25, 2006

Errors in thyroid gland fine-needle aspiration.

May 31, 2006

Clinical impact and frequency of anatomic pathology errors in cancer diagnoses.

October 26, 2005

Quality in cancer diagnosis.

May 26, 2010

Frequency and outcome of cervical cancer prevention failures in the United States.

December 19, 2007

The effect of a Lean quality improvement implementation program on surgical pathology specimen accessioning and gross preparation error frequency.

September 1, 2012

Effectiveness of random and focused review in detecting surgical pathology error.

January 14, 2009

Anatomic pathology databases and patient safety.

October 19, 2005

Patient identification error among prostate needle core biopsy specimens—are we ready for a DNA time-out?

November 7, 2007

Dissemination of Lean methods to improve Pap testing quality and patient safety.

April 8, 2008

Assessment of latent factors contributing to error: addressing surgical pathology error wisely.

November 16, 2011

Directed peer review in surgical pathology.

September 1, 2012

Patient safety in anatomic pathology: measuring discrepancy frequencies and causes.

April 15, 2005

The "Big Dog" effect: variability assessing the causes of error in diagnoses of patients with lung cancer.

July 19, 2006

Liquid-based Papanicolaou tests in endometrial carcinoma diagnosis: performance, error root cause analysis, and quality improvement.

February 1, 2012

Improving Papanicolaou test quality and reducing medical errors by using Toyota production system methods.

January 18, 2006

Identification errors involving clinical laboratories: a College of American Pathologists Q-Probes study of patient and specimen identification errors at 120 institutions.

August 16, 2006

Specimen labeling errors: a Q-probes analysis of 147 clinical laboratories.

November 12, 2008

Laboratory medicine handoff gaps experienced by primary care practices: a report from the Shared Networks of Collaborative Ambulatory Practices and Partners (SNOCAP).

December 3, 2014

Interpretive diagnostic error reduction in surgical pathology and cytology: guideline from the College of American Pathologists Pathology and Laboratory Quality Center and the Association of Directors of Anatomic and Surgical Pathology.

June 17, 2015

The current and ideal state of anatomic pathology patient safety.

July 30, 2014

To make or buy patient safety solutions: a resource dependence and transaction cost economics perspective.

July 13, 2011

Resident participation does not affect surgical outcomes, despite introduction of new techniques.

September 22, 2010

You can't blame the wreck on the train.

February 8, 2017

Defending a "never event."

August 2, 2017

Year-end resident clinic handoffs: narrative review and recommendations for improvement.

February 15, 2017

Mistake-proofing healthcare: why stopping processes may be a good start.

March 3, 2010

The impact of anti-infective drug shortages on hospitals in the United States: trends and causes.

February 8, 2012

The disruptive orthopaedic surgeon: implications for patient safety and malpractice liability.

November 23, 2011

Board of pharmacy practices related to medication errors and their potential impact on patient safety.

August 1, 2018

Translating patient safety legislation into health care practice.

November 29, 2006

Psychology of error in relation to medical practice.

March 6, 2005

Safe use of electronic health records and health information technology systems: trust but verify.

December 18, 2013

The 80-hour work guidelines and resident survey perceptions of quality.

November 15, 2006

Procedural timeout compliance is improved with real-time clinical decision support.

September 12, 2018

Is patient safety improving? National trends in patient safety indicators: 1998–2007.

January 30, 2005

Getting doctors to report medical errors: project DISCLOSE.

July 5, 2006

Risk factors for retained instruments and sponges after surgery.

March 6, 2005

Wrong site surgery near misses and actual occurrences.

August 26, 2009

On patient safety: when are we too old to operate?

March 9, 2016

Getting surgery right.

September 12, 2007

Relationship between patient safety and hospital surgical volume.

December 7, 2011

The role for leaders of health care organizations in patient safety.

September 19, 2007

Team mental models and their potential to improve teamwork and safety: a review and implications for future research in healthcare.

May 2, 2012

Missed it.

March 27, 2013

Prevention of retained surgical sponges: a decision-analytic model predicting relative cost-effectiveness.

May 27, 2009

Cause and effect analysis of closed claims in obstetrics and gynecology.

May 18, 2005

Adoption of patient-centered care practices by physicians: results from a national survey.

April 26, 2006

Developing a quality and safety curriculum for fellows: lessons learned from a neonatology fellowship program.

October 30, 2013

Self-Reported Learning (SRL), a voluntary incident reporting system experience within a large health care organization.

May 12, 2021

Functional health literacy and understanding of medications at discharge.

July 16, 2008

Harnessing the power of medical malpractice data to improve patient care.

January 8, 2020

The Broselow tape as an effective medication dosing instrument: a review of the literature.

October 10, 2012

Assessing the impact of an educational program on decreasing prescribing errors at a university hospital.

April 1, 2009

The medicolegal aspect of error in pathology: a search of jury verdicts and settlements.

April 25, 2007

Effects of an intervention to increase bed alarm use to prevent falls in hospitalized patients: a cluster randomized trial.

December 12, 2012

Reducing the risk of adverse drug events in older adults.

April 17, 2013

Health care consumers' inclination to engage in selected patient safety practices: a survey of adults in Pennsylvania.

December 12, 2007

Delivering on the promise of CLER: a patient safety rotation that aligns resident education with hospital processes.

August 8, 2018

Improving safety by evaluating the impact of the supply chain and drug shortages on health-systems.

March 29, 2023

Hastened death due to disease burden and distress that has not received timely, quality palliative care is a medical error.

August 12, 2020

A realist synthesis of pharmacist-conducted medication reviews in primary care after leaving hospital: what works for whom and why?

December 2, 2020

Increased mortality associated with after-hours and weekend admission to the intensive care unit: a retrospective analysis.

April 20, 2011

Management of anesthesia equipment failure: a simulation-based resident skill assessment.

August 19, 2009

Incident reporting in surgical trainees-revisited.

August 13, 2008

Improving resident morning sign-out by use of daily events reports.

March 4, 2015

Postoperative opioid prescribing and the pain scores on Hospital Consumer Assessment of Healthcare Providers and Systems survey.

June 7, 2017

Automated dispensing cabinets.

August 15, 2007

Interhospital transfer handoff practices among US tertiary care centers: a descriptive survey.

May 4, 2016

Hierarchy and medical error: speaking up when witnessing an error.

April 8, 2020

How U.S. teams advanced communication and resolution program adoption at local, state and national levels.

January 13, 2021

Teaching quality improvement and patient safety in residency education: strategies for meaningful resident quality and safety initiatives.

August 23, 2017

Recommendations and low-technology safety solutions following neuromuscular blocking agent incidents.

February 3, 2016

Publicly available hospital comparison web sites: determination of useful, valid, and appropriate information for comparing surgical quality.

September 26, 2007

A hospital is not just a factory, but a complex adaptive system—implications for perioperative care.

August 2, 2017

Clinical benefits of electronic health record use: national findings.

January 15, 2014

Beyond our walls: impact of patient and provider coordination across the continuum on outcomes for surgical patients.

February 21, 2007

Understanding pharmacist decision making for adverse drug event (ADE) detection.

April 15, 2009

Insulin pump risks and benefits: a clinical appraisal of pump safety standards, adverse event reporting, and research needs: a joint statement of the European Association for the Study of Diabetes and the American Diabetes Association Diabetes Technology Working Group.

May 6, 2015

Intraoperative sentinel events in the era of surgical safety checklists: results of a national survey.

March 3, 2021

Association between waiting times and short term mortality and hospital admission after departure from emergency department: population based cohort study from Ontario, Canada.

June 15, 2011

Family-centered multidisciplinary rounds enhance the team approach in pediatrics.

April 15, 2009

CT for suspected appendicitis in children: an analysis of diagnostic errors.

March 1, 2006

Emergency intubation of children outside of the operating room.

February 26, 2020

A comprehensive obstetrics patient safety program improves safety climate and culture.

April 20, 2011

STOPP/START criteria for potentially inappropriate prescribing in older people: version 2.

December 10, 2014

Association of state opioid duration limits with postoperative opioid prescribing.

January 29, 2020

Association between long-term opioid use in family members and persistent opioid use after surgery among adolescents and young adults.

March 13, 2019

Changes in early high-risk opioid prescribing practices after policy interventions in Washington State.

October 28, 2020

Decision making in trauma settings: simulation to improve diagnostic skills.

March 11, 2015

Hospital-Acquired Condition Reduction Program is not associated with additional patient safety improvement.

December 4, 2019

Using "near misses" analysis to prevent wrong-site surgery.

October 30, 2013

"Excuse me": teaching interns to speak up.

August 28, 2013

Does employee safety matter for patients too? Employee safety climate and patient safety culture in health care.

May 20, 2015

Incidence, patterns, and prevention of wrong-site surgery.

April 19, 2006

Predicting future staffing needs at teaching hospitals: use of an analytical program with multiple variables.

April 25, 2007

Impact of computerised physician order entry (CPOE) on the incidence of chemotherapy-related medication errors: a systematic review.

April 7, 2021

Combined proactive risk assessment: unifying proactive and reactive risk assessment techniques in health care.

June 29, 2022

Procedural safety in emergency care: a conceptual model and recommendations.

October 24, 2012

Related Resources

Diagnostic errors in musculoskeletal oncology and possible mitigation strategies.

May 24, 2023

Blood and blood products transfusion errors: what can we do to improve patient safety.

May 10, 2023

Closing the loop on test results to reduce communication failures: a rapid review of evidence, practice and patient perspectives.

November 25, 2020

COVID-19: making the right diagnosis.

August 5, 2020

Reducing diagnostic errors worldwide through diagnostic management teams.

April 3, 2019

Electronic patient identification for sample labeling reduces wrong blood in tube errors.

March 20, 2019

Diagnostic error as a result of drug-laboratory test interactions.

March 6, 2019

Transfusion safety: the nature and outcomes of errors in patient registration.

February 20, 2019

Impact of interactions between drugs and laboratory test results on diagnostic test interpretation—a systematic review.

November 21, 2018

Blood sampling guidelines with focus on patient safety and identification—a review.

October 31, 2018

Interventions to improve follow-up of laboratory test results pending at discharge: a systematic review.

March 14, 2018

A systematic review of interventions to follow-up test results pending at discharge.

February 7, 2018

Disclosure of harmful medical error to patients: a review with recommendations for pathologists.

February 7, 2018

Patient perceptions of receiving test results via online portals: a mixed-methods study.

January 17, 2018

WebM&M Cases

A Costly Colonoscopy Leads to a Delay in Diagnosis

January 1, 2018

WebM&M Cases

Delayed Diagnosis of Endocrinologic Emergencies

November 1, 2017

WebM&M Cases

Specimen Almost Lost

November 1, 2017

Clinician perspectives on the management of abnormal subcritical tests in an urban academic safety-net health care system.

October 4, 2017

Nil per os orders for imaging: a teachable moment.

September 27, 2017

WebM&M Cases

Failed Interpretation of Screening Tool: Delayed Treatment

September 1, 2017

Diagnostic stewardship—leveraging the laboratory to improve antimicrobial use.

August 16, 2017

Assigning responsibility to close the loop on radiology test results.

July 12, 2017

Pediatric radiology malpractice claims—characteristics and comparison to adult radiology claims.

July 12, 2017

WebM&M Cases

Delayed Recognition of a Positive Blood Culture

July 1, 2017

Blood bank specimen mislabeling: a College of American Pathologists Q-Probes study of 41,333 blood bank specimens in 30 institutions.

June 7, 2017

Characteristics associated with requests by pathologists for second opinions on breast biopsies.

May 17, 2017

Pathologists' perspectives on disclosing harmful pathology error.

May 3, 2017

WebM&M Cases

Hemolysis Holdup

May 1, 2017

Managing the patient identification crisis in healthcare and laboratory medicine.

March 22, 2017

Improving patient safety: avoiding unread imaging exams in the National VA enterprise electronic health record.

Pathology and patient safety: the critical role of pathology informatics in error reduction and quality initiatives.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Pathology and patient safety: the critical role of pathology informatics in error reduction and quality initiatives.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

PSNet Log in

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site