Error Reduction and Prevention in Surgical Pathology Raouf E. Nakhleh Editor Error Reduction and Prevention in Surgical Pathology 1 3 Editor Raouf E. Nakhleh Pathology Mayo Clinic 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 Springer Cham Heidelberg New York Dordrecht London © Springer Science+Business Media New York 2015 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, express or implied, with respect to the material contained herein or for any errors or omissions that may have been made. Printed on acid-free paper 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 v vi Contents 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 Hospital, 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 Calgary, Pathology and Laboratory Medicine Calgary Laboratory Services, Foothills Medical Centre, Calgary, AB, Canada Keith E. Volmar Rex Pathology Associates, Raleigh, NC, USA.