Improving Patient Safety by Examining Pathology Errors

Citation:
Raab SS, Grzybicki DM, Mahood LK, et al. Effectiveness of random and focused review in detecting surgical pathology error. Am J Clin Pathol 2008;130:905-912.

Summary:
This cohort study was conducted at a large institution that practices subspecialty surgical pathology sign-out in order to compare the effectiveness and usefulness of error detection.

Citation:
Raab SS, Grzybicki DM, Condel JL, et al. Effect of Lean method implementation in the histopathology section of an anatomic pathology laboratory. J Clin Pathol 2008;61:1193-1199. Epub 2007 Aug 3.

Summary:
The purpose of this study was to measure the effect of implementation of a Lean quality improvement process on the efficiency and quality of a histopathology laboratory section.

Citation:
Meier FA, Zarbo RJ, Varney RC, et al. Amended reports: development and validation of a taxonomy of defects. Am J Clin Pathol 2008:130:238-246.

Summary:
Amended pathology reports produce rework, confusion, and distrust. The authors of this article derived a classification from amended reports to develop a reproducible amendment taxonomy.

Citation:
Raab SS, Grzybicki DM. Multi-institutional database of anatomic pathology errors. Diagn Histopathol 2008;14:316-323.

Summary:
In 2002, AHRQ funded a consortium of institutions to study the current state of anatomic pathology error. This consortium designed and constructed an anatomic pathology error database that was used to benchmark institutional frequencies, causes and outcomes of error. The aggregated and institutional data showed high variability in practice and that anatomic pathology errors generally were caused by multiple system failures, often occurring in the pre-analytic and post-analytic testing phases. The consortium used these data to design error reduction initiatives that were implemented in practices.

Citation:
Raab SS, Grzybicki DM. Measuring quality in anatomic pathology. Clin Lab Med 2008;28:245-259.

Summary:
This article focuses mainly on diagnostic accuracy in measuring quality in anatomic pathology, noting that measuring any quality metric is complex and demanding. The authors discuss standardization and its variability within and across areas of care delivery and efforts involving defining and measuring error to achieve pathology quality and patient safety.

Citation:
Raab SS, Andrew-Jaja C, Grzybicki DM, et al. Dissemination of Lean methods to improve Pap testing quality and patient safety. J Low Genit Tract 2008;12:103-110.

Summary:
The objective of this study was to determine if the implementation of Lean methods resulted in improved Pap test quality and diagnostic accuracy in 5 clinician practices.

Citation:
Raab SS, Grzybicki DM. Technology and process and cervical cancer prevention. Am J Clin Pathol 2008;129:187-189.

Summary:
The article describes new technologies such as liquid-based preparations designed to improve the screening phase of cervical cancer prevention.

Citation:
Grzybicki DM, Raab SS, Janosky JE, et al. Anatomic pathology and patient safety: it's not an error: it's a diagnostic misadventure! Am J Clin Pathol 2008;129:167-168.

Summary:
No abstract available.

Citation:
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.

Summary:
By adopting a cultural transformation in its employees' approach to work and using manufacturing based continuous quality improvement methods, the surgical pathology division of Henry Ford Hospital, Detroit, MI, focused on reducing commonly encountered defects and waste in processes throughout the testing cycle.

Citation:
Geisinger KR, Vrbin C, Grzybicki DM, et al. Interobserver variability in human papillomavirus test results in cervicovaginal cytologic specimens interpreted as atypical squamous cells. Am J Clin Pathol 2007;128:1010-1014.

Summary:
This study examined interobserver variability in the proportions of human papillomavirus (HPV)-positive results for atypical squamous cells of undetermined significance (ASCUS) and atypical squamous cells.

Citation:
Raab SS, Grzybicki DM, Zarbo RJ, et al. Frequency and outcome of cervical cancer prevention failures in the United States. Am J Clin Pathol 2007;128:817-824.

Summary:
This study measured the frequency and outcome of cervical cancer prevention failures that occurred in the Papanicolaou (Pap) and colposcopy testing phases involving Pap tests in four American hospital systems between January 1, 1998, and December 31, 2004.

Citation:
Suba EJ, Pfeifer JD, Raab SS. Patient identification error among prostate needle core biopsy specimens: are we ready for a “DNA timeout?” J Urol 2007;178:1245-1248.

Summary:
Patient identification errors in surgical pathology often involve switches of prostate or breast needle core biopsy specimens among patients. This study assessed strategies for decreasing the occurrence of these uncommon and yet potentially catastrophic events.

Citation:
D'Angelo R, Zarbo RJ. The Henry Ford Production System: Measures of process defects and waste in surgical pathology as a basis for quality improvement initiatives. Am J Clin Pathol 2007;128:423-429.

Summary:
Researchers implemented a continuous quality improvement initiative in pursuit of a "zero-defects" performance goal in surgical pathology that required design of novel data collection tools to assess our current condition and sources of defects and waste.

Citation:
Raab SS, Grzybicki DM, Vrbin CM, et al. Urine cytology discrepancies: frequencies, causes, and outcomes. Am J Clin Pathol 2007;127:946-953.

Summary:
This study obtained histologic follow-up in voided, lower tract instrumented, and upper tract urinary cytologic specimens from one institution during a 2-year timeframe to determine diagnostic discrepancy frequency and outcomes.

Citation:
Stark A, Jones BA, Chapman D, et al. Clinical laboratory specimen rejection: Association with the site of patient care and patients' characteristics. Findings from a single health care organization. Arch Pathol Lab Med 2007;131:588-592.

Summary:
The objective of this study was to calculate the proportions of rejected specimens stratified by point of collections and demographic information of patients.

Citation:
Grzybicki DM, Raab SS. Measuring health care performance. Identification and standardization of laboratory quality indicators. Am J Clin Pathol 2006;126(Suppl 1):S48-S52.

Summary:
This article considers the prospect of some form of pay-for-performance (P4P) incentive program by federal and private payers. It discusses limitations to the implementation of P4P for laboratory services, such as the lack of a group of nationally standardized quality performance metrics to validly use for performance comparisons between laboratories and for benchmarking, lack of standardized quality metrics, and resistance among pathologists and other laboratory professionals to promote and undertake this collaborative task.

Citation:
Zarbo RJ, D'Angelo R. Transforming to a quality culture: The Henry Ford Production System. Am J Clin Pathol (Pathol Patterns Reviews) 2006;126(Suppl 1):S21-S29.

Summary:
This article describes the cultural transformation of the surgical pathology laboratory at Henry Ford Hospital, Detroit, MI, to one that has adopted an expectation for empowered workers to see their daily work in the context of continually learning and making effective process improvements that are designed and tested by the scientific method.

Citation:
Grzybicki DM, Merryman TE, Sharbaugh D, et al. The second annual improving hospital and laboratory safety meeting: discussion session proceedings. Am J Clin Pathol 2006;126(Suppl 1):S7-S11.

Summary:
In May 2006, the Second Annual Improving Hospital and Laboratory Safety Meeting was held at the University of Pittsburgh, Pittsburgh, PA. This meeting was designed to bring pathology laboratory professionals and nonlaboratory health care professionals who use laboratory diagnostic testing services together with patient safety experts to discuss current evidence regarding errors and error-reduction methods associated with all phases of laboratory diagnostic testing, identify priority areas in pathology laboratory diagnostic testing services to target for quality improvement (QI) initiatives, and present specific QI changes that attendees could consider implementing in their laboratories.

Citation:
Raab SS, Grzybicki DM, Janosky JE, et al. The Agency for Healthcare Research and Quality Hospital Labs Studying Patient Safety (AHRQ-HLPS) Consortium and Patient Safety. Am J Clin Pathol 2006;126(Suppl 1):S12-S20.

Summary:
In 2002, AHRQ funded a consortium of hospital laboratories to study errors in the anatomic pathology diagnostic testing pathway. Nine laboratories are consortium members and share error data, perform root cause analysis, and design and implement error reduction initiatives. These laboratories have established baseline error frequencies and determined the causes of diagnostic, sampling, identification, and reporting errors. These laboratories have shown that interpretive variability is a major impediment to error reduction. During the last several years, error-reduction interventions have been attempted in many areas of anatomic pathology. Interventions such as double-slide viewing and process redesign have been shown to reduce significantly error proportions.

Citation:
Raab SS, Stone CH, Wojcik EM, et al. Use of a new method in reaching consensus on the cause of cytologic-histologic correlation discrepancy. Am J Clin Pathol 2006;126:836-842.

Summary:
This observational study developed a visual method of adjudicating discrepancy cause, termed the No-Blame Box method, which consisted of initially assessing specimen interpretability by separately evaluating specimen quality and the presence of tumor.

Citation:
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.

Summary:
The objective of this study was to determine whether the Toyota Production System process redesign resulted in diagnostic error reduction for patients who underwent cytologic evaluation of thyroid nodules.

Citation:
Raab SS, Meier FA, Zarbo RJ, et al. The “Big Dog” Effect: Variability Assessing the Causes of Error in Diagnoses of Patients with Lung Cancer. J Clin Oncol 2006;24:2808-2814.

Summary:
The frequency of diagnostic error in patients who have a lung mass and a pathology specimen is as high as 15%. This study examined the role of inter-pathologist agreement in identifying the cause of error in these patients.

Citation:
Raab SS, Grzybicki DM. Anatomic pathology workload and error. Am J Clin Pathol 2006;125:809-812.

Summary:
This editorial examines the findings of an article in the same issue of this journal (Renshaw and Gould) that reported that pathologist workload was not a significant driver of pathology error. It considers the perspective of psychology of error as well as other studies on workload and medical error.

Citation:
Raab SS, Vrbin CM, Grzybicki DM, et al. Errors in thyroid gland fine needle aspiration. Am J Clin Pathol 2006:125:873-882.

Summary:
This study measured the performance metrics of thyroid gland fine-needle aspiration, performed root cause analysis to determine the causes of error, and proposed error-reduction initiatives to address specific errors.

Citation:
Raab SS. Improving patient safety through quality assurance. Arch Pathol Lab Med 2006;130:633-637.

Summary:
This article reviewed some of the anatomic pathology laboratory patient safety quality assurance practices.

Citation:
Raab SS, Stone CH, Jensen CS, et al. Double slide viewing as a cytology quality improvement initiative. Am J Clin Pathol 2006;125:526-533.

Summary:
This study measured the effect of pre-sign out double viewing of cytology cases as a means to decrease error.

Citation:
Raab SS, Andrew-Jaja C, Condel JL, et al. Improving Pap test quality and reducing medical errors by using Toyota Production System methods. Am J Obstet Gyn 2006;194:57-64.

Summary:
The objective of the study was to determine whether the Toyota production system process improves Papanicolaou test quality and patient safety.

Citation:
Nodit L, Balassanian R, Sudilovsky D, et al. Improving the quality of cytology diagnosis: root cause analysis for errors in bronchial washing and brushing specimens. Am J Clin Pathol 2005;124:883-893.

Summary:
This study performed root cause analysis of all false-negative bronchial brushing and washing specimen errors detected by the cytologic-histologic correlation process in 2002.

Citation:
Raab SS, Grzybicki DM, Janosky JE, et al. Clinical impact and frequency of anatomic pathology errors in cancer diagnosis. Cancer 2005;104:2205-2213.

Summary:
This article examined errors in patients who underwent anatomic pathology tests to determine the presence or absence of cancer or precancerous lesions in four hospitals.

Citation:
Raab SS, Grzybicki DM, Zarbo RJ, et al. Anatomic pathology databases and patient safety. Arch Pathol Lab Med 2005;129:1246-1251.

Summary:
This article outlines how databases may be used to study anatomic pathology patient safety.

Citation:
Grzybicki DM, Turcsanyi B, Becich MJ, et al. Database construction for improving patient safety by examining pathology errors. Am J Clin Pathol 2005;124:1-10.

Summary:
"Improving Patient Safety by Examining Pathology Errors" is a project designed to collect data about and analyze diagnostic errors voluntarily reported by four academic anatomic pathology laboratories and to develop and implement interventions to reduce errors and improve patient outcomes. The study database is Web-mediated and Oracle-based, and it houses de-identified error data detected by cytologic-histologic correlation and interdepartmental conference review. This article describes the basic design of the database with a focus on challenges faced as a consequence of the absence of standardized and detailed laboratory workload and quality assurance data sets in widely used laboratory information systems and the lack of efficient and comprehensive electronic de-identification of unlinked institutional laboratory information systems and clinical data.

Citation:
Zarbo RJ, Sirota R. Error and error reduction in pathology. Arch Pathol Lab Med 2005;129:1228-1233.

Summary:
The objectives of this study were to review the fundamental conclusions of the Institute of Medicine's report on medical error, to provide a taxonomy of error that can be adapted to pathology, to provide a framework for studying and analyzing error in pathology, to contrast different approaches to error, and to explain the concept of a culture of safety.

Citation:
Zarbo RJ, Meier FA, Raab SS. Error detection in anatomic pathology. Arch Pathol Lab Med 2005;129:1237-1245.

Summary:
The objectives of this study were to define the magnitude of error occurring in anatomic pathology, to propose a scheme to classify such errors so their influence on clinical outcomes can be evaluated, and to identify quality assurance procedures able to reduce the frequency of errors.

Citation:
Vrbin CM, Grzybicki DM, Zaleski MS, et al. Variability in cytologic-histologic correlation practices and implications on patient safety. Arch Pathol Lab Med 2005;129:893-898.

Summary:
The objective of this study was to determine the similarities and differences in how laboratories perform cytologic-histologic correlation.

Citation:
Raab SS. Variability in anatomic pathology practice and its effect on patient outcome. Semin Diagn Pathol 2005;22:177-185.

Summary:
This article discusses variability in the delivery of medical care, how it negatively affects patient outcomes and contributes to escalating health care costs, and efforts to reduce such as the development of evidence-based clinical practice guidelines.

Citation:
Dhir J, Condel JL, Raab SS. Identification and correction of errors in the anatomic pathology gross room. Pathol Case Rev 2005;10:79-82.

Summary:
This case report describes an incident in which there was an error in specimen accessioning. The error was detected; however, the case had been signed out the previous day. The authors performed a root cause analysis to assess the sequence of events and identify all possible sources of errors.

Citation:
Condel JL, Jukic DM, Sharbaugh DT, et al. Histology errors: use of real-time root cause analysis to improve practice. Pathol Case Rev 2005;10:82-87.

Summary:
This case review illustrates how methods such as the Toyota Production System process may be used to detect and correct errors occurring in histology.

Citation:
Parwani AV, Raab SS. Amended report resulting from an interpretation error: a case report and review of the literature. Pathol Case Rev 2005;10:74-78.

Summary:
This article reports the case of a patient, a 63-year-old man, who presented with hematuria and cystoscopy, which revealed a bladder mass. Two biopsies were performed by different pathologists, which resulted in different interpretations.

Citation:
Becich MJ, Gilbertson JR, Gupta D, et al. Pathology and patient safety: the critical role of pathology informatics in error reduction and quality initiatives. Clin Lab Med 2004;24:913-943.

Summary:
This article provides a short alphabetized introduction to several "buzzwords" and terms related to tools and processes that are used by health care research experts and workers involved in patient safety initiatives. It also includes short descriptions of key health care research and patient safety projects that are relevant to pathology and aims to highlight the areas where pathology informatics can play a role in promoting patient safety.

Citation:
Raab SS. Improving patient safety by examining pathology errors. Clin Lab Med 2004;24:849-863.

Summary:
A considerable void exists in the information available regarding anatomic pathology diagnostic errors and their impact on clinical outcomes. To fill this void and improve patient safety, four institutional pathology departments (University of Pittsburgh, Western Pennsylvania Hospital, University of Iowa Hospitals and Clinics, and Henry Ford Hospital System) have proposed the development of a voluntary, Web-based, multi-institutional database for the collection and analysis of diagnostic errors. These institutions intend to use these data proactively to implement internal changes in pathology practice and to measure the effect of such changes on errors and clinical outcomes.

Citation:
Condel JR, Sharbaugh DT, Raab SS. Error-free pathology: applying lean production methods in anatomic pathology. Clin Lab Med 2004;24:865-899.

Summary:
This article is intended to share the authors' experiences in applying a lean production method to their anatomic pathology department, not only to reduce pathology errors to zero but to change a "blame culture" to one in which frontline staff members become effective problem solvers and the source of system improvements.