Difference between revisions of "Quality"

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==Analysis==
==Analysis==
===Overview===
Quality issues are examined a number of different ways, e.g. root cause analysis, failure mode and effects analysis (FMEA).
Quality issues are examined a number of different ways, e.g. root cause analysis, failure mode and effects analysis (FMEA).


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===Failure-potential analysis===
====Failure-potential analysis====
Adapted from Ullman:<ref name=ullman>{{cite book |title=The mechanical design process |last= Ullman |first = David G. |authorlink= |coauthors= |year= 1997 |publisher= McGraw-Hill Companies Inc. |location= Toronto|isbn=0-07-065756-4 |page= |pages= |url= |accessdate=}}</ref>
Adapted from Ullman:<ref name=ullman>{{cite book |title=The mechanical design process |last= Ullman |first = David G. |authorlink= |coauthors= |year= 1997 |publisher= McGraw-Hill Companies Inc. |location= Toronto|isbn=0-07-065756-4 |page= |pages= |url= |accessdate=}}</ref>
#Identify potential individual failures.
#Identify potential individual failures.
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#Identify how the individual failures can arise.
#Identify how the individual failures can arise.
#Identify the corrective action.
#Identify the corrective action.
===Error analysis===
*Pathology errors happen any time from when the lab gets the specimen until after the report is isssued.
When errors happen:
*Work-up problem - where did it occur.
*Talk to clinican - if it is a ''[[critical diagnosis]]'' contact most-responsible physician... if unreachable physician on-call for the most-responsible physician.
*Talk to chief of pathology.
*Incident report.
*Reconstruct error.
**Is there another error? (What it a specimen mix-up?)
*Amend report(s).
*Remedy source of error.
Pre-analytic:
*Container mix-up - pre-lab & in-lab.
*Block mix-up.
*Slide mix-up - labels wrong.
*Poor quality slides (fixation, processing, staining).
Analytic:
*Interpretation wrong.
**Difficult case.
**Technical factors (quality of slides).
Post-analytic:
*Wrong case signed-out.
*Filing problem.
*Interpretation of report problem (poorly written, bad interpretation).


==Error reduction==
==Error reduction==

Revision as of 04:14, 22 January 2012

Quality, in pathology, has got a lot of attention lately because there have been high profile screw-ups that lead to significant harm.[1]

Analysis

Overview

Quality issues are examined a number of different ways, e.g. root cause analysis, failure mode and effects analysis (FMEA).

A common way to break down error analysis is:

 
 
 
 
 
 
 
 
Errors in pathology
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Pre-analytical errors
 
 
Analytical errors
 
 
Post-analytical errors

Failure-potential analysis

Adapted from Ullman:[2]

  1. Identify potential individual failures.
  2. Identify the consequences of those failures.
  3. Identify how the individual failures can arise.
  4. Identify the corrective action.

Error analysis

  • Pathology errors happen any time from when the lab gets the specimen until after the report is isssued.

When errors happen:

  • Work-up problem - where did it occur.
  • Talk to clinican - if it is a critical diagnosis contact most-responsible physician... if unreachable physician on-call for the most-responsible physician.
  • Talk to chief of pathology.
  • Incident report.
  • Reconstruct error.
    • Is there another error? (What it a specimen mix-up?)
  • Amend report(s).
  • Remedy source of error.

Pre-analytic:

  • Container mix-up - pre-lab & in-lab.
  • Block mix-up.
  • Slide mix-up - labels wrong.
  • Poor quality slides (fixation, processing, staining).

Analytic:

  • Interpretation wrong.
    • Difficult case.
    • Technical factors (quality of slides).

Post-analytic:

  • Wrong case signed-out.
  • Filing problem.
  • Interpretation of report problem (poorly written, bad interpretation).

Error reduction

Various strategies can be employed:[3]

  • Training of staff - on error handling.
  • Computer order entry.
    • Avoid duplication fatigue.
    • Quick correlation with several identifying features.
      • Full name, sex, date of birth -- these all appear when one opens a case.
  • Barcode use.
    • Avoid transcription errors.
  • Clinical information entry required.
    • Allow correlation with test.
      • The interpretation may differ if the history says "screening coloscopy" versus "large cecal mass, anemia and weight loss".

Other strategies:

  • Statistical process control.

Sources of error

  • "Human error".
    • Training.
    • Work flow.
  • Process gaps.
    • Process control.
    • Lack of redundancy.

Biopsy size

Very small tissue fragments are associated with a decreased diagnostic yield and an increased diagnostic uncertainty.

Immunohistochemistry

Main article: Immunohistochemistry

A paper by Torlakovic et al.[4] divides immunohistochemistry (IHC) tests into:

  • Class I:
    • Adjunct to histomorphology.
    • Examples: CD45, S-100.
  • Class II:
    • Considered independent of the other information in the pathology report; thus, cannot be derived from other information in the report.
    • Used directly for treatment decisions.
    • Examples: ER, PR, HER2.

See also

References

  1. ↑ URL: http://www.attorneygeneral.jus.gov.on.ca/inquiries/goudge/index.html. Accessed on: 1 March 2011.
  2. ↑ Ullman, David G. (1997). The mechanical design process. Toronto: McGraw-Hill Companies Inc.. ISBN 0-07-065756-4.
  3. ↑ Fabbretti, G. (Jun 2010). "Risk management: correct patient and specimen identification in a surgical pathology laboratory. The experience of Infermi Hospital, Rimini, Italy.". Pathologica 102 (3): 96-101. PMID 21171512.
  4. ↑ Torlakovic, EE.; Riddell, R.; Banerjee, D.; El-Zimaity, H.; Pilavdzic, D.; Dawe, P.; Magliocco, A.; Barnes, P. et al. (Mar 2010). "Canadian Association of Pathologists-Association canadienne des pathologistes National Standards Committee/Immunohistochemistry: best practice recommendations for standardization of immunohistochemistry tests.". Am J Clin Pathol 133 (3): 354-65. doi:10.1309/AJCPDYZ1XMF4HJWK. PMID 20154273.
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