It's Our Turn: Implications for Pathology From the Institute of Medicine's Report on Diagnostic Error

Laposata, Michael; Cohen, Michael B.

doi:10.5858/arpa.2015-0499-ed

Cited by 18 publications

(29 citation statements)

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“…Likewise, pathologists could enhance their diagnostic performance both by giving feedback about test selection, interpretation and errors to treating physicians, and by receiving regular feedback about these issues from clinicians. More accurate pathologic diagnosis should reduce medical error [34,35].…”

Section: Radiologists Pathologists and The Diagnostic Management Teammentioning

confidence: 99%

The new diagnostic team

et al. 2017

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Abstract:The National Academy of Medicine (NAM) in the recently issued report Improving Diagnosis in Health Care outlined eight major recommendations to improve the quality and safety of diagnosis. The #1 recommendation was to improve teamwork in the diagnostic process. This is a major departure from the classical approach, where the physician is solely responsible for diagnosis. In the new, patient-centric vision, the core team encompasses the patient, the physician and the associated nursing staff, with each playing an active role in the process. The expanded diagnostic team includes pathologists, radiologists, allied health professionals, medical librarians, and others. We review the roles that each of these team members will need to assume, and suggest "first steps" that each new team member can take to achieve this new dynamic.

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Section: Radiologists Pathologists and The Diagnostic Management Teammentioning

confidence: 99%

The new diagnostic team

et al. 2017

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“…Such errors have the potential to consume patient and provider time, increasing costs, while diminishing trust in the health care system. Experts in the field of pathology are only beginning to understand the implications of the 1999 IOM report on their specialty, with particular emphasis on a need for collaboration with other specialties, including surgery [10].…”

Section: Discussionmentioning

confidence: 99%

“…There was also a degree of confusion following the second biopsy, generating unnecessary work and consuming additional resources. Finally, appropriate disclosure of errors should be provided to the patient in order to help foster mutual trust and understanding [10].…”

Section: Clinical Vignette #1: Discussion Of "Lessons Learned"mentioning

confidence: 99%

“…Despite the relative commonality of labeling errors, research on their prevalence and consequences is sparse [10]. To elucidate the nature of error in specimen/patient labeling, large Q-PROBES studies have been conducted, with one study noting an error rate of 6% involving specimen identification and accession defects, with specimen misidentification constituting nearly 10% of the errors [34,35].…”

Section: Clinical Vignette #1: Discussion Of "Lessons Learned"mentioning

confidence: 99%

“…The Quality Practices Committee and College of American Pathologists (CAP) designed validated guidelines and metrics in laboratory quality, with data collection and peer review initiatives such as Q-PROBES (a peer-comparison quality assurance service offered by the College of American Pathologists that was created in 1989), in order to establish patient safety benchmarks [9]. However, despite increased awareness, the necessity of improving pre-existing pathology paradigms has only been considered recently [10]. Additionally, an expert panel from The CAP, as well as the Pathology and Laboratory Quality Center, in association with the Association of Directors of Anatomic and Surgical Pathology, drafted several recommendations aimed at avoiding interpretative errors, ultimately designating case review as an effective deterrence to error [11].…”

Section: Introductionmentioning

confidence: 99%

See 2 more Smart Citations

Patient Safety Issues in Pathology: From Mislabeled Specimens to Interpretation Errors

Tang¹,

Dowbeus²,

Firstenberg³

et al. 2018

Vignettes in Patient Safety - Volume 3

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Catastrophic breaches in patient safety often involve point-of-care settings such as the operating theater or intensive care unit, quite frequently without due consideration given to the elements leading up to such errors. Among such occurrences, wrong site procedures (WSPs) and diagnostic discrepancies continue to result in significant morbidity and mortality among patients. Addressing adverse events is difficult for all stakeholders involved. Furthermore, clinician familiarity with the workflow specific to particular disciplines or procedures may be poor, amplifying communication lapses that precede patient safety occurrences. The patient care paradigm has become increasingly multidisciplinary, and it is important to discuss, improve, and be more cognizant of measures required to achieve "zero defect" performance. Despite the rarity of "never events," their consequences may damage patient and community trust, provider morale, and institutional reputation. This chapter aims to assess current preventive measures and risks in the context of errors involving surgical pathology in the setting of the operating theater utilizing the framework of clinical vignettes. The discussion below will further center on the practical and interpretative errors that occur in the pathological workflow, and the potential for compounding of such errors in the operating theater. Definitions concerning WSP and diagnostic discrepancies will be outlined to characterize potential outcomes of communication errors.

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Reduction of diagnostic error: Following cytopathology’s lead

Heher

2020

Cancer Cytopathology

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Diagnostic error remains a significant and preventable source of harm for patients worldwide. As many as 12 million diagnostic errors may occur each year in the United States, contributing to from 40,000 to 80,000 deaths. 1,2 One in 3 Americans report having personally experienced a diagnostic error, and one-third of those report significant harm as a result. 3,4 Medical malpractice claims resulting from diagnostic error account for the largest fraction of claims filed, the most severe patient harm, and the highest dollar payouts. 5 The true incidence and death rates because of diagnostic error may be disputed, but the challenge of diagnostic error and the importance of addressing it have never been in doubt. Efforts to address diagnostic error had been focused until relatively recently on missed or delayed diagnoses by primary care or emergency room physicians or by radiologists who face the challenge of incidental findings. In 2015, for the first time, the pathology community entered the larger conversation around diagnostic error when the National Academy of Medicine (NAM; formerly the Institute of Medicine [IOM]) issued its report Improving Diagnosis in Medicine, the third part of a seminal series that began with its 1999 publication To Err is Human. 6 Two pathologists, who were the first in our specialty to participate in the NAM/IOM committee that authored the 2015 report, subsequently wrote an editorial entitled in part It's Our Turn. 7 The editorial outlined specific steps pathologists should consider to reduce diagnostic error. These steps included collaborative teamwork, enhanced education and training about the diagnostic process, adopting a safety culture, focusing on health information technology, and making other strategic changes to reduce error. Although more than 4 years have passed since these clear calls to action, many in the pathology community would agree that we have a long way to go to fully integrate quality and safety principles into pathology and laboratory medicine. Ownership of the full test cycle and failures in communication are particularly challenging problems that are reinforced by administrative silos, complex and growing health care networks, and inadequate information technology. Our community has maintained a sharp focus on regulatory requirements but is still seeking ways to embrace fully the safety-oriented recommendations that have the potential to dramatically lower diagnostic error in the laboratory. Cytopathology has been a bright spot in pathology quality and safety. Since the advent of the Clinical Laboratory Improvement Amendments Act in 1988 and, subsequently, with the widespread adoption of the Bethesda System, the Milan System, the Paris System, and others, cytopathologists have been at the leading edge of quality, safety, and communication. 8-12 The culture of cytotechnologists, cytopathologists, and their laboratories has led to a near universal focus on concordance, accuracy, and degree of certainty. The cytology report was the first clinical laboratory report ...

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It's Our Turn: Implications for Pathology From the Institute of Medicine's Report on Diagnostic Error

Cited by 18 publications

References 1 publication

The new diagnostic team

The new diagnostic team

Patient Safety Issues in Pathology: From Mislabeled Specimens to Interpretation Errors

Reduction of diagnostic error: Following cytopathology’s lead

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