Pre‐analytic error: A significant patient safety risk

Heher, Yael K.; Chen, Yigu; VanderLaan, Paul A.

doi:10.1002/cncy.22019

Cited by 20 publications

(22 citation statements)

References 13 publications

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“…The postanalytic phase comprises correct reporting, interpretation, and delivery of the report. Although the majority of errors occur in the preanalytic phase, approximately 10% of errors are attributable to the analytic portion 2 …”

Section: Introductionmentioning

confidence: 99%

Erroneous diagnosis of primary fibrosarcoma of the breast: The value of the multidisciplinary breast team approach

et al. 2021

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Diagnostic errors occur in the preanalytic, analytic, and postanalytic phases of specimen processing. Correlating clinical and imaging information with gross and microscopic findings is crucial to limit errors and unnecessary treatment. Herein, we report the case of a 54-year-old woman who presented with left breast bloody nipple discharge and subsequently underwent central duct excision. Pathology revealed a highgrade sarcoma. The patient presented to our institution for further management.Upon secondary pathology review and DNA fingerprinting analysis, the correct interpretation was rendered. Our case demonstrates the importance of clinical correlation and review of pathology slides prior to definitive therapy.

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Section: Introductionmentioning

confidence: 99%

Erroneous diagnosis of primary fibrosarcoma of the breast: The value of the multidisciplinary breast team approach

et al. 2021

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“…13 Most major threats to the quality of laboratory services occur in the preanalytic and postanalytic phases of testing. 14 Postanalytic quality, related to the correct communication of results, was a particular focus of the 2015 NAM/IOM report. Yet our training as pathologists and virtually all of the widely adopted cytopathology classification systems focus on analytic quality-the portion of the test cycle entirely controlled by pathologists.…”

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confidence: 99%

“…Most major threats to the quality of laboratory services occur in the preanalytic and postanalytic phases of testing 14 . Postanalytic quality, related to the correct communication of results, was a particular focus of the 2015 NAM/IOM report.…”

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confidence: 99%

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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“…Laboratories that provide high-quality and reliable results address analytic and postanalytic sources of error directly, but preanalytic errors (eg, specimen mislabeling or loss), which are the largest source of risk in laboratory testing, frequently occur outside of the laboratory domain. [1][2][3][4] Pathologists often have limited oversight of practices in clinical areas collecting specimens, yet elimination of specimen-mislabeling errors remains a Joint Commission National Patient Safety Goals priority for laboratories, 5 and, ultimately, quality systems in pathology must address and mitigate all sources of preanalytic error to be effective.…”

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confidence: 99%

Radio-Frequency Identification Specimen Tracking to Improve Quality in Anatomic Pathology

Norgan

Simon

Feehan

et al. 2019

Archives of Pathology &Amp; Laboratory Medicine

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Context.— Preanalytic errors, including specimen labeling errors and specimen loss, occur frequently during specimen collection, transit, and accessioning. Radio-frequency identification tags can decrease specimen identification and tracking errors through continuous and automated tracking of specimens. Objective.— To implement a specimen tracking infrastructure to reduce preanalytic errors (specimen mislabeling or loss) between specimen collection and laboratory accessioning. Specific goals were to decrease preanalytic errors by at least 70% and to simultaneously decrease employee effort dedicated to resolving preanalytic errors or investigating lost specimens. Design.— A radio-frequency identification specimen-tracking system was developed. Major features included integral radio-frequency identification labels (radio-frequency identification tags and traditional bar codes in a single printed label) printed by point-of-care printers in collection suites; dispersed radio-frequency identification readers at major transit points; and systems integration of the electronic health record, laboratory information system, and radio-frequency identification tracking system to allow for computerized physician order entry driven label generation, specimen transit time tracking, interval-based alarms, and automated accessioning. Results.— In the 6-month postimplementation period, 6 mislabeling events occurred in collection areas using the radio-frequency identification system, compared with 24 events in the 6-month preimplementation period (75% decrease; P = .001). In addition, the system led to the timely recovery of 3 lost specimens. Labeling expenses were decreased substantially in the transition from high-frequency to ultrahigh frequency radio-frequency identification tags. Conclusions.— Radio-frequency identification specimen tracking prevented several potential specimen-loss events, decreased specimen recovery time, and decreased specimen labeling errors. Increases in labeling/tracking expenses for the system were more than offset by time savings and loss avoidance through error mitigation.

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Pre‐analytic error: A significant patient safety risk

Cited by 20 publications

References 13 publications

Erroneous diagnosis of primary fibrosarcoma of the breast: The value of the multidisciplinary breast team approach

Erroneous diagnosis of primary fibrosarcoma of the breast: The value of the multidisciplinary breast team approach

Reduction of diagnostic error: Following cytopathology’s lead

Radio-Frequency Identification Specimen Tracking to Improve Quality in Anatomic Pathology

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