Error Reduction and Prevention in Surgical Raouf E. Nakhleh Editor

Error Reduction and Prevention in Surgical Pathology

1 3 Editor Raouf E. Nakhleh Pathology Mayo Florida Jacksonville Florida USA

ISBN 978-1-4939-2338-0 ISBN 978-1-4939-2339-7 (eBook) DOI 10.1007/978-1-4939-2339-7

Library of Congress Control Number: 2014960069

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Springer is part of Springer Science + Business Media (www.springer.com) Contents

1 Introduction ������������������������������������������������������������������������������������������������ 1 Raouf E. Nakhleh

2 The Landscape of Error in Surgical Pathology ��������������������������������������� 3 Frederick A. Meier

3 General Principles of How Errors Occur and How They May Be Reduced ���������������������������������������������������������������������������������������� 27 Maxwell L. Smith and Stephen S. Raab

Part I Pre-Analytic Factors Contributing to Errors and Error Prevention

4 Error Reduction in the Preanalytical Process ����������������������������������������� 43 Richard W. Brown

5 Application of Lean Principles to Preanalytic and Analytic Processes ������������������������������������������������������������������������������� 59 Anil Vasdev Parwani, Seung Lyung Park and Liron Pantanowitz

Part II Analytic Factors Contributing to Errors and Error Prevention

6 Clinical History and Clinical Correlation ������������������������������������������������ 85 Keith E. Volmar

7 Knowledge, Training, and Experience ����������������������������������������������������� 103 Amelia Huck and Vania Nosé

8 Standardization of Diagnostic Terminology and Criteria: A Prelude for Error Reduction ��������������������������������������������������������������������� 115 Raouf E. Nakhleh

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9 Ancillary Studies: Contribution to Error and Error Prevention ���������� 127 Paul E. Swanson

10 Optimization of Case Reviews in Different Practice Settings ���������������� 149 Raouf E. Nakhleh

Part III Post-analytic Factors Leading to Errors and Error Prevention

11 The Complete Surgical Pathology Report ����������������������������������������������� 163 Michael O. Idowu

12 Communicating Effectively in Surgical Pathology ��������������������������������� 185 Carolyn Mies

13 Error Prevention in Transcription and Report Distribution ����������������� 197 Shannon J. McCall

14 Error Management: Legal and Regulatory Responsibilities ����������������� 209 Timothy Craig Allen

Index ������������������������������������������������������������������������������������������������������������������ 221 Contributors

Timothy Craig Allen Department of Pathology, The University of Texas Medical Branch, Galveston, TX, USA Richard W Brown System Laboratory Services, Memorial Hermann Healthcare System, Houston, TX, USA Amelia Huck Department of Pathology, Massachusetts General , Boston, MA, USA Michael O. Idowu Department of Pathology, Virginia Commonwealth University Health System, Richmond, VA, USA Shannon J. McCall Department of Pathology, Duke University, Durham, NC, USA Frederick A. Meier Department of Pathology and Laboratory Medicine, Henry Ford Hospital, Detroit, MI, USA Department of Pathology, School of Medicine, Wayne State University, Detroit, MI, USA Carolyn Mies Division of Anatomic Pathology, Department of Pathology & Laboratory Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA Raouf E. Nakhleh Department of Pathology, Mayo Clinic Florida, Jacksonville, FL, USA Vania Nosé Anatomic and Molecular Pathology, Massachusetts General Hospital, Boston, MA, USA Liron Pantanowitz Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA Seung Lyung Park Department of Pathology, University of Alabama in Birmingham, Birmingham, AL, USA

vii viii Contributors

Anil Vasdev Parwani Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA Stephen S. Raab Department of Laboratory Medicine, University of Washington and Memorial University of Newfoundland, Seattle, WA, USA Maxwell L. Smith Department of Laboratory Medicine and Pathology, Mayo Clinic Arizona, Scottsdale, AZ, USA Paul E. Swanson Cumming School of Medicine, University of , Pathology and Laboratory Medicine Calgary Laboratory Services, Foothills Medical Centre, Calgary, AB, Canada Keith E. Volmar Rex Pathology Associates, Raleigh, NC, USA