… disagreements and errors, conducting case reviews in a timely fashion, and continuously tracking and documenting …

… J Am Board Fam Med … J Am Board Fam Med … This survey-based study of primary care providers revealed a lack of standardization for the tracking, receiving , and … lost. … West DR, James KA, Fernald DH, Zelie C, Smith ML, Raab SS. Laboratory medicine handoff gaps experienced by …

This commentary illustrates the process of decision-making in pathology to reveal factors contributing to disagreements in interpretation of test results. Emphasizing how differences between slow thinking and fast thinking can cause interpretation errors, the author recommends system-level approaches and team-based solutions, respectively, to improve safety in pathology.

Surgical specimen identification errors occur regularly and preventing misidentification errors is a National Patient Safety Goal. This study reports on an effort to develop process measures for monitoring the quality of specimen identification.

Entering pathology test results into the wrong patient’s record but discovering the error before the results are released is a type of pathology near miss. Using Lean quality improvement program (LQIP), including culture change, one anatomic pathology laboratory sought to reduce both process- and operator-dependent near-miss events. The laboratory was able to decrease the frequency of process-dependent near-miss events, though not the operator-dependent events. The authors cite lack of leadership buy-in as a major challenge.  

Diagnostic error in pathology can result in delayed treatment or initiation of incorrect treatment. Peer review, or second opinion, is used by many laboratories to improve diagnostic accuracy and precision. This paper describes the use of Lean A3 method to identify and reduce root causes of cognitive and latent errors in pathology misdiagnosis.

… Am J Clin Pathol … Delayed diagnosis from false-negative … initiatives were implemented. … Sams SB,  Currens HS, Raab SS. Liquid-based Papanicolaou tests in endometrial … error root cause analysis, and quality improvement. Am J Clin Pathol. 2012;137(2):248-254. 10.1309/ajcplfbk1a2xjdqi …

This study used root cause analysis to identify latent factors that contributed to near misses in processing surgical pathology specimens.

Looking across 136 institutions, this study quantified mislabeling rates at a cumulative total of 0.11% for cases, specimens, blocks, and slides. The authors reinforce the need for quality monitoring since most errors were caught in the immediate steps following the error.

… CA: a cancer journal for clinicians … CA Cancer J Clin … This review discusses quality of pathology testing … calls for improvements to prevent diagnostic errors . … Raab SS, Grzybicki DM. CA Cancer J Clin. 2010;60:139-165.   …

Lean thinking strategies were applied to improve workflow and reduce misidentification errors in a surgical pathology laboratory. Following redesign of workflows, the overall misidentification rate reduced by 62% and a 95% reduction in slide misidentification defects. 

… American journal of clinical pathology … Am J Clin Pathol … This study found that a focused review process detects a higher proportion of surgical pathology errors than a …

… Laboratories with ongoing quality monitoring programs had a lower incidence of specimen labeling errors, as did …

Lean methodology is a quality improvement method to increase safety and efficiency in healthcare. In this small study, five clinicians in a gynecology practice used Lean methods to redesign the workflow to improve the diagnostic accuracy of Pap tests. Although two clinicians dropped out of the study, the remaining three improved Pap test quality and diagnostic accuracy, maintained up to six months.

… American journal of clinical pathology … Am J Clin Pathol … This AHRQ-funded study of cervical cancer screening results found a remarkably low incidence of missed malignancies. The … suits in ambulatory care. Although a prior study by Raab and colleagues found a higher overall error rate in …

This study summarizes the findings from three root cause analyses to highlight the challenges in preventing patient identification errors in surgical pathology specimens. The authors suggest the use of a time-out strategy that would reduce the risk of the wrong patient receiving radiation or surgical therapy.

… American journal of clinical pathology … Am J Clin Pathol … The authors compared the frequency of diagnostic error for a thyroid aspiration service before and after applying error …

The investigators analyzed information on misidentified laboratory specimens and found that such errors are common. Most errors are detected prior to results being communicated and are rarely associated with adverse patient incidents.

… journal of the American Society of Clinical Oncology … J Clin Oncol … The AHRQ–funded researchers analyzed … pathologist reluctance to change or challenge a peer's reading is a contributing factor. …