[1993] Root Cause Analysis of Discordant and Deferred Frozen Section Diagnoses

Shaikh A Mortuza, Michael Bonert, Beverly Rowe, Frank X Torres, Stephen S Raab. Eastern Health and Memorial University of Newfoundland, St. John's, Newfoundland, Canada

Background: Frozen section (FS) intraoperative consultation provides information that appropriately guides patient care. We examined failures in pathology steps leading to discordant and deferred FS diagnoses using a hierarchical root cause method that categorized cause into active and system components related to the pathology process steps. From these data, we derived a rule book/checklist for improved practice.
Design: We performed a retrospective review of 427 consecutive FS cases from the past 3 years to retrieve 11 (2.5%) discordant and 15 (3.5%) deferred cases. These failures first were classified by originating process step: gross sampling, technical, interpretation, and reporting. We then used an Ishikawa fishbone diagram to classify root causes into the 6 categories of human factor, methods, equipment, materials, measures, and culture. We then examined the groups of causes to determine interventions specifically focusing on lowering system noise resulting in ambiguous signals for pathologist interpretation and introducing cognitive task rules that would assist pathologists in producing the highest quality diagnosis.
Results: We classified the failure origination step as 8 in the gross sampling and technical, 13 in the interpretation, and 5 across all. Seven failures had tumor on permanent sections (no tumor on FS), but our evaluation showed contributing factors originating in the sampling phase. The fishbone diagram showed large numbers of contributing causes for all errors in the categories of human, methods, measures, and culture components. Contributing human factor causes included insufficient decision making education (22), cognitive bias (4), and insufficient technical skill education (3). All failures had cultural causes, including 9 cases in which the pathologist lacked appropriate back-up expertise. All failures had multiple method component causes, as no existing practice rules or procedures were in place. The developed checklist included rules for all process steps (e.g., sampling rules for specific cases) and incorporated system changes affecting the 6 categories of root cause.
Conclusions: All failures in intraoperative FS had a large number of contributing causes generally related to system processes. Human factor components had a large role in most failures and generally related to failures in decision making based on communication with limited data, bias, and lack of system support. We hypothesize that our rule book/checklist will lower specific failure types by targeting root causes that are systemic rather than individual.
Category: Quality Assurance

Tuesday, March 5, 2013 9:30 AM

Poster Session III # 263, Tuesday Morning


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