Improving patient safety by examining pathology errors

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. They believe that the successful implementation of this project will result in the study of other types of diagnostic pathology error and the expansion to national participation. The project will involve the collection of multi-institutional anatomic pathology diagnostic errors in a large database that will facilitate a more detailed analysis of these errors, including their effect on patient outcomes. Participating institutions will perform root cause analysis for diagnostic errors and plan and execute appropriate process changes aimed at error reduction. The success of these interventions will be tracked through analysis of postintervention error data collected in the database. Based on their preliminary studies, these institutions proposed the following specific aims: Specific aim #1: To use a Web-based database to collect diagnostic errors detected by cytologic histologic correlation and by second-pathologist review of conference cases. Specific aim #2: To analyze the collected error data quantitatively and generate quality performance reports that are useful for institutional quality improvement programs. Specific aim #3: To plan and implement interventions to reduce errors and improve clinical outcomes, based on information derived from root cause analysis of diagnostic errors. Specific aim #4: To assess the success of implemented interventions by quantitative measure of postinterventional errors and clinical outcomes and by qualitative assessment by project participants. Funding for this project was approved by the Agency for Health Care Research and Quality in September 2002, and data collection and analysis are ongoing. Over 5000 errors have been collected in the database, and the clinical outcomes of these errors have been tracked. At a national meeting in November 2003, root cause analysis was performed to determine causes of errors. The findings of these root cause analyses have been presented at national pathology meetings and are currently being published.     

Quality and patient safety in the diagnosis of breast cancer

The media, medical legal, and safety science perspectives of a laboratory medical error differ and assign variable levels of responsibility on individuals and systems. We examine how the media identifies, communicates, and interprets information related to anatomic pathology breast diagnostic errors compared to groups using a safety science Lean-based quality improvement perspective. The media approach focuses on the outcome of error from the patient perspective and some errors have catastrophic consequences. The medical safety science perspective does not ignore the importance of patient outcome, but focuses on causes including the active events and latent factors that contribute to the error. Lean improvement methods deconstruct work into individual steps consisting of tasks, communications, and flow in order to understand the affect of system design on current state levels of quality. In the Lean model, system redesign to reduce errors depends on front-line staff knowledge and engagement to change the components of active work to develop best practices. In addition, Lean improvement methods require organizational and environmental alignment with the front-line change in order to improve the latent conditions affecting components such as regulation, education, and safety culture. Although we examine instances of laboratory error for a specific test in surgical pathology, the same model of change applies to all areas of the laboratory.     

Unsuspected internal organ traumatic injuries

Emergency medicine physicians can avoid missed traumatic intra-abdominal injury by adopting a paradigm for patient evaluation that recognizes the patterns of injury associated with pathology, the importance of positive and negative physical findings, and the limitations of diagnostic studies. The burden of avoiding missed traumatic injuries does not rest with emergency medicine physicians alone, however. A missed diagnosis may be the result of a medical error involving multiple systems and individuals.Ultimately, decreasing the incidence of missed traumatic injury is an opportunity for quality improvement for all practitioners involved in the care of patients with trauma.     

A successful practice model for the OR

A practice model that combines shared governance and patient care teamwork to achieve optimal surgical patient care provided the framework for a successful Joint Commission on Accreditation of Healthcare Organizations visit at the Brigham and Women's Hospital, Boston, a university-affiliated teaching hospital. This article describes ways to implement this practice model. Clinical practice, quality improvement, and development councils are explained, as well as membership criteria for the councils and how they function. The need for more sharing of such quality improvement data from other hospitals is needed to establish national standards for measuring nursing performance.     

Exploring the iceberg of errors in laboratory medicine

The last few decades have seen a significant decrease in the rates of analytical errors in clinical laboratories, and currently available evidence demonstrates that the pre- and post-analytical steps of the total testing process (TTP) are more error-prone than the analytical phase. In particular, most errors are identified in pre-pre-analytic and post-post analytic steps outside the walls of the laboratory, and beyond its control. However, in a patient-centered approach to the delivery of health care services, there is the need to investigate any possible defect in the total testing process that may have a negative impact on the patient. In fact, in the interests of patients, any direct or indirect negative consequence related to a laboratory test must be considered, irrespective of which step is involved and whether the error is caused by a laboratory professional (e.g., calibration or testing error) or by a non-laboratory operator (e.g., inappropriate test request, error in patient identification and/or blood collection). Data on diagnostic errors in primary care and in the emergency department setting demonstrate that inappropriate test requesting and incorrect interpretation account for a large percentage of total errors whatever the discipline involved, be it radiology, pathology or laboratory medicine. Patient misidentification and problems in communicating results, which affect the delivery of all diagnostic services, are widely recognized as the main goals for quality improvement. Therefore, some common problems affect diagnostic errors, although specific faults characterising errors in laboratory medicine should lead to preventive and corrective actions if evidence-based quality indicators are developed, implemented and monitored. The lesson we have learned is that each practice must examine its own total testing process to discover its weaknesses and identify appropriate remedies.     

Integrating quality control and external quality assurance

Effective management of clinical laboratories relies upon an understanding of Quality Control and External Quality Assurance principles. These processes, when applied effectively, reduce patient risk and drive quality improvement. In this Review, we will describe the purpose of QC and EQA and their role in identifying analytical and process error. The two concepts are linked, and we will illustrate that linkage. Some EQA providers offer far more than analytical surveillance. They facilitate training and education and extend quality improvement and identify areas where there is potential for patient harm into the pre-and post-analytical phases of the total testing process.     

Patient safety: getting there from here--quality management is the best patient safety program.

Historical management activities such as quality control (QC) and quality assurance (QA) have not prevented medical errors or patient safety problems related to the laboratory. Reports of laboratory quality assurance activities provide evidence of the need for significant improvement in the total laboratory path of workflow when measured on the Six Sigma scale. The old paradigm has been: people are the cause of medical errors and the solution is to name, blame, and shame them. This bias is being replaced by a new awareness that system failures cause medical errors and that a systematic process management approach to improving patient safety can prevent these hazards.     

Identification errors in pathology and laboratory medicine

Identification errors involve misidentification of a patient or a specimen. Either has the potential to cause patients harm. Identification errors can occur during any part of the test cycle; however, most occur in the preanalytic phase. Patient identification errors in transfusion medicine occur in 0.05% of specimens; for general laboratory specimens the rate is much higher, around 1%. Anatomic pathology, which involves multiple specimen transfers and hand-offs, may have the highest identification error rate. Certain unavoidable cognitive failures lead to identification errors. Technology, ranging from bar-coded specimen labels to radio frequency identification tags, can be incorporated into protective systems that have the potential to detect and correct human error and reduce the frequency with which patients and specimens are misidentified.     

Designing and implementing a patient safety program for the OR

Surgery has a high potential for adverse outcomes. An error involving a retained retractor caused perioperative nurses at the University of Washington Medical Center, Seattle, to take another look at their department's patient safety practices and risk management procedures. Using another department's successful program as a model, the nurses considered the frameworks of risk management, quality improvement, and OR culture to develop a new patient safety quality improvement program for the OR. This article details the process of designing and implementing the program, which has energized staff members, enhanced teamwork, and resulted in improved patient outcomes. AORN J 76 (Sept 2002) 452-456.     

Evidence‐based medicine: A cornerstone for clinical care but not for quality improvement

Quality improvement (QI) as a clinical improvement science has been criticized for failing to deliver broad patient outcome improvement and for being a top‐down regulatory and compliance construct. These critics have argued that the focus of QI should be on increasing adherence to clinical practice guidelines (CPGs) and, as a result, should be consolidated into research structures with the science of evidence‐based medicine (EBM) at the helm. We argue that EBM often overestimates the role of knowledge as the root cause of quality problems and focuses almost exclusively on the effectiveness of care while often neglecting the domains of safety, efficiency, patient‐centredness, and equity. Successfully addressing quality problems requires a much broader, systems‐based view of health‐care delivery. Although essential to clinical decision‐making and practice, EBM cannot act as the cornerstone of health system improvement.     

SHEL 模式在分析护理差错事故中的作用

目的：探讨差错形成原因及SHEL模式在分析差错事故中作用的方法：通过对2005年在该院52个护理单元所发生的50例差错的随月份分布、差错类别构成分析，以及用SHEL模式和护理差错环节分析法对每l例差错进行分析，提出相关改进措施，在全院交流。结果：2007年1-10月该院共发生差错26例。与2006年比较差异有统计学意义，P＜0 .01。结论：倡导缺陷分享文化,正视差错的危害性，分享缺陷经验，才能不断提高护理质量，更好地为广大病人服务。     

Monitoring anatomic pathology practice through quality assurance measures

This article describes the art and science of continuous performance measurement and applications for quality improvement in anatomic pathology. Numerous novel benchmarks derived from multi-institutional data acquired from the College of American Pathologists Q-Probes quality improvement program are illustrated as they relate to specific disciplines in anatomic pathology and aspects of the total testing cycle. Comparative data quantifying performance deficiencies and opportunities for practice improvement are also identified.     

Effective strategies to increase reporting of medication errors in hospitals

A major concern for patient safety in hospitals is accurate medication administration. To improve the medication administration process, nurses and pharmacists must report system problems. Although staff supported the concept of medication error reporting, they did not report errors. Inherent fear of retribution, punitive actions, and professional humiliation prevented self-reporting of medication errors. Our hospital's quality improvement department developed, implemented, and evaluated a program called LifeSavers. Its purpose was to build a nonpunitive culture and to increase medication error reporting by staff. In one year, the LifeSavers program increased medication error disclosures from 14 to 72 reports per month. The successful development of a nonblame culture of medication error reporting led to identified sources of problems and improvement of the medication administration system.     

Barriers to the implementation of patient safety initiatives

Since release of the Institute of Medicine Report "To Err is Human:Building a Safer Health System" in 1999, a huge effort has been expended on error-related clinically applied research and on the implementation of new standards and practices related to quality improvement and patient safety. Nonetheless, measurable improvements in the quality of delivered care and reductions in medical errors have been variable and modest in most cases. Multiple barriers to the implementation of patient safety and error reduction initiatives have been identified in the literature. The greater part of this article is devoted to three fundamental barriers: physicians' intolerance for uncertainty, health professionals' fears, and an organizational structure and culture that are incongruent with increasing patient safety.     

Use of Patient-Reported Outcomes: Rationale and Clinical Implementation

Routine collection and use of patient-reported outcomes (PROs) benefits patients, providers, and health care organizations. PROs are useful in clinical decision making, in measuring and improving patient experience, in research, and in quality improvement. They are of increasing fiscal importance as payers transition to value-based reimbursement. Through a quality improvement project using a Plan-Do-Study-Act framework, team members developed a process to increase the PRO collection rate from 4% to more than 85% of eligible clinic visits. Incorporation of PRO collection into the clinic workflow is facilitated by multidisciplinary collaboration and recognition of the value generated by the process.     

Quality management within a cost-constrained service

AIM: To examine the meaning of quality and ways in which quality can be improved despite budgetary limitations. KEY ISSUES: Definitions of quality are discussed, comparing the development from industrial concepts of quality to that contained within the Department of Health's A First CLASS SERVICE: The relationship of cost and quality is examined and the effects of changing treatments on healthcare costs explored. Clinical error is identified as a cause of increased cost through failure to maintain quality. A variety of quality tools are discussed in identifying ways in which quality can be improved within a cost-limited service. Thrombolysis is used as an exemplar and the effects on nursing discussed. CONCLUSION: There is research evidence which demonstrates that some areas of quality are amenable to improvement despite budgetary constraints.     

L’erreur médicamenteuse: nouveaux textes de loi et expériences en France

Drug error is the omission or the non-intentional realization of an act during the drug process that may harm the patient. The error may be confirmed, potential or latent. Drug errors are the most frequent among medical errors. Age (older and younger patients) and co-morbidities are the commonly reported risk factors for drug errors. Two recent French laws regarding the management of drug errors in the hospital are presented. The hospital, patient, health, territory (HPST) law (July 2009) assigns the management of quality and safety of health care to hospitals. The law focusing on the quality of drug management in hospitals (April 2011) recommends to set up a quality management system in each hospital to ensure the quality and security of drug use. In addition, a national evaluation of drug errors has been organized, allowing a direct intervention of national health authorities to modify drug presentation and labeling, if required. Two examples of drug error management processes, one in a university hospital and the other in an intensive care unit, are presented. Multidisciplinary management, absence of informant sanction, and collection of anonymous data are the reasons for the success of those systems. If a drug error is related to practices, then analysis and improvement of practices by local management are mandatory. Participation of all health professionals involved in the drug process as well as a strong commitment of hospital staff are the two essential conditions to make the drug error management process successful.     

Info-tsunami: surviving the storm with data quality probes

As a result of the rapid expansion of electronically available clinical knowledge, clinicians are faced with potential information overload (info-tsunami). The use of data quality probes (DQPs) in primary care can encourage clinicians' awareness of, and improvement in, data quality entry over time. DQPs can also highlight areas of potential error or omission as well as good practice, which can impact directly upon the quality of patient care. In this paper, five specific conditions have been subjected to the use of a series of DQPs over a five-year period in order to assess and measure the performance of different initiatives on the quality of data capture and patient care.     

Failure prevention in clinical practice through identification of failure examples

"Learning from ones mistakes" is an essential part of clinical quality improvement. But focusing on a retrospective analysis of mishaps from the past is not sufficient for quality enhancements, nor is the restriction to mistakes in the solely legal sense. Analysis has to include anonymous data aggregated over dissatisfying results from multiple sources. Recognizing patterns of underlying causes for errors is the key to effective error prevention. In many cases the true cause might be predominantly organizational.     

Value of the electronic scalpel (cut mode) in the evaluation of the fetal face.

OBJECTIVES: To evaluate the improvement of image quality and diagnostic value of fetal face examinations using the electric scalpel. METHODS: A total of 232 cases were examined. The fetuses were separated into two groups: Group A, including normal fetuses (n = 152) and Group B, fetuses with facial pathology (n = 80). The fetuses were divided into eight subgroups according to gestational age (9-12 weeks, 13-16 weeks, 17-20 weeks, 21-24 weeks, 25-28 weeks, 29-32 weeks, 33-36 weeks and 37-40 weeks). RESULTS: The number of cutting steps for the improvement of image quality ranged from 1 to 9 (mean value 3) in the group of normal fetuses and from 1 to 10 (mean value 3) in the group of fetuses with facial pathology. In the group of normal fetuses, superior image quality improvement was achieved in 68.4% of cases, moderate improvement in 28.9% and poor improvement in 2.6%. In the group of fetuses with facial pathology, high image quality improvement was obtained in 72.5% of cases, moderate improvement in 25.0% and insufficient improvement in 2.5%. There were no differences among the eight subgroups in the number of steps required relating to gestational age. CONCLUSIONS: The use of the electronic scalpel was associated with diagnostic improvement in 71.1% of cases in the group of normal fetuses, and in 75.0% in the group of fetuses with facial pathology.