[2004] Dissecting Errors in the Histology Laboratory

Sergey M Pyatibrat, Jeffrey D Goldsmith, Stephen S Raab, Yael B Kushner. Beth Israel Deaconess Medical Center, Boston, MA; Eastern Health Authority, St-John's, Newfoundland, Canada

Background: Previous studies have examined error and the role of quality improvement in surgical pathology. Although various steps of specimen processing have been assessed, there is variation in the reported rates of defects. Methods of data collection regarding error are not universal and make current data difficult to replicate at other institutions. Little data exist on vulnerable steps in the histology laboratory workflow. We undertook a study of occurring errors in the histology laboratory in order to dissect their nature and causes.
Design: In this study, we evaluate errors in the histology laboratory at a major academic center with an annual surgical specimen volume of approximately 60,000. Errors were defined as labeling incidents or processes that may have resulted in significant patient harm if they were not corrected prior to reaching the patient. We created a numerical step key (NSK) identifying all steps in the histology laboratory workflow from accessioning to slide pick-up by the pathologist. An error log was created using the NSK to document vulnerable steps and timing of error capture, along with date/time of error, original accession number, error description, action taken, re-work time, and whether the error was internal (caught within the laboratory) or external (released to the pathologist). Notably, an error at a single step was counted only once, omitting the “domino” effect of carry-over errors. The data were collected utilizing self-reporting by technicians, laboratory system administrators, residents, and pathologists.
Results: The data were collected over a 5 month period, with a total case number of 24324. The histology workflow NSK included 53 steps. The error rate was 1.0% ± 0.3% (244 errors in total). All errors were subdivided into internal and external to the laboratory. Internal errors accounted for 81% of all defects. The majority of errors (76%) were attributed to transcription, whereas cutting and pick-up errors accounted for 21%. On average, histology staff spent 6.4 minutes (min=1, max=120) rectifying a single error, which resulted in nearly 26 hours of wasted time over the study period.
Conclusions: Errors are surprisingly frequent occurrences in the histology laboratory. They are a major source of liability for clinically important diagnostic errors and have the potential for serious adverse events and patient harm. This study dissects types, locations, and rates of error in order to target specific vulnerable steps amenable to process change and quality improvement.
Category: Quality Assurance

Monday, March 4, 2013 9:30 AM

Poster Session I Stowell-Orbison/Surgical Pathology/Autopsy Awards Poster Session # 300, Monday Morning


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