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Lamothe S, Peric M, Glickman JN, Heher YK. Erroneous Patient Tissue Contaminants in 1574 Surgical Pathology Slides: Impact on Diagnostic Error and a Novel Framework for Floater Management. Arch Pathol Lab Med 2023; 147:1413-1421. [PMID: 36730470 DOI: 10.5858/arpa.2022-0265-oa] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/05/2022] [Indexed: 02/04/2023]
Abstract
CONTEXT.— Tissue contaminants on histology slides represent a serious risk of diagnostic error. Despite their pervasive presence, published peer-reviewed criteria defining contaminants are lacking. The absence of a standardized diagnostic workup algorithm for contaminants contributes to variation in management, including investigation and reporting by pathologists. OBJECTIVE.— To study the frequency and type of tissue contaminants on microscopic slides using standardized criteria. Using these data, we propose a taxonomy and algorithm for pathologists on "floater" management, including identification, workup, and reporting, with an eye on patient safety. DESIGN.— A retrospective study arm of 1574 histologic glass slides as well as a prospective study arm of 50 slide contamination events was performed. Using these data we propose a structured classification taxonomy and guidelines for the workup and resolution of tissue contamination events. RESULTS.— In the retrospective arm of the study, we identified reasonably sized benign tissue contaminants on 52 of 1574 slides (3.3%). We found size to be an important parameter for evaluation, among other visual features including location on the slide, folding, ink, and tissue of origin. The prospective arm of the study suggested that overall, pathologists tend to use similar features when determining management of potentially actionable contaminants. We also report successfully used case-based ancillary testing strategies, including fluorescence in situ hybridization analysis of chromosomes and DNA fingerprinting. CONCLUSIONS.— Tissue contamination events are underreported and represent a patient safety risk. Use of a reproducible classification taxonomy and a standardized algorithm for contaminant workup, management, and reporting may aid pathologists in understanding and reducing risk.
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Affiliation(s)
- Simon Lamothe
- From the Department of Pathology, Beth Israel Deaconess Medical Center, Boston, Massachusetts (Lamothe, Peric, Glickman)
| | - Masa Peric
- From the Department of Pathology, Beth Israel Deaconess Medical Center, Boston, Massachusetts (Lamothe, Peric, Glickman)
| | - Jonathan N Glickman
- From the Department of Pathology, Beth Israel Deaconess Medical Center, Boston, Massachusetts (Lamothe, Peric, Glickman)
| | - Yael K Heher
- The Department of Pathology, Massachusetts General Hospital, Boston (Heher)
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Harris CK, Chen Y, Alston EL, Brown A, Chabot-Richards D, Dintzis SM, Graber ML, Jackups Jr. R, Lomo LC, Laudadio J, Markwood PS, Nielson KJ, Samedi V, Sampson B, Haspel RL, Zafar N, Montone KT, Childs J, White KL, Heher YK. The next phase in patient safety education: Towards a standardized, tools-based pathology patient safety curriculum: A call to action from the Association of Pathology Chairs' Residency Program Directors Section Training Residents in Patient Safety Workgroup. Acad Pathol 2023; 10:100081. [PMID: 37313035 PMCID: PMC10258240 DOI: 10.1016/j.acpath.2023.100081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 01/26/2023] [Accepted: 01/29/2023] [Indexed: 06/15/2023] Open
Abstract
Patient safety education is a mandated Common Program Requirement of the Accreditation Council for Graduate Medical Education and for the Royal College of Physicians and Surgeons of Canada in all medical residency and fellowship programs. Although many hospitals and healthcare environments have general patient safety education tools for trainees, few to none focus on the unique training milieu of pathologists, including a mix of highly automated and manual error-prone processes, frequent multiplicity of events, and lack of direct patient relationships for error disclosure. We established a national Association of Pathology Chairs-Program Directors Section Workgroup focused on patient safety education for pathology trainees entitled Training Residents in Patient Safety (TRIPS). TRIPS included diverse representatives from across the United States, as well as representatives from pathology organizations including the American Board of Pathology, the American Society for Clinical Pathology, the United States and Canadian Academy of Pathology, the College of American Pathologists, and the Society to Improve Diagnosis in Medicine. Objectives of the workgroup included developing a standardized patient safety curriculum, designing teaching and assessment tools, and refining them with pilot sites. Here we report the establishment of TRIPS as well as data from national needs assessment of Program Directors across the country, who confirmed the need for a standardized patient safety curriculum.
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Affiliation(s)
- Cynthia K. Harris
- Department of Pathology, Massachusetts General Hospital, Boston, MA, USA
- The New York City Office of Chief Medical Examiner, New York, NY, USA
| | - Yigu Chen
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Erin L. Alston
- Department of Pathology, Brigham and Women's Hospital, Boston, MA, USA
| | - Ali Brown
- American Society for Clinical Pathology, Chicago, IL, USA
| | | | - Suzanne M. Dintzis
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, WA, USA
| | - Mark L. Graber
- Society to Improve Diagnosis in Medicine, Evanston, IL, USA
| | - Ronald Jackups Jr.
- Department of Pathology and Immunology, Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Lesley C. Lomo
- Department of Pathology, University of Utah Health, Salt Lake City, UT, USA
| | - Jennifer Laudadio
- Department of Pathology, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | | | | | - Von Samedi
- Department of Pathology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Barbara Sampson
- Department of Pathology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Richard L. Haspel
- Department of Pathology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Nadeem Zafar
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, WA, USA
| | - Kathleen T. Montone
- Department of Pathology and Laboratory Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - John Childs
- Department of Pathology, Geisinger Medical Center, Danville, PA, USA
| | - Kristie L. White
- Departments of Pathology and Laboratory Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Yael K. Heher
- Department of Pathology, Massachusetts General Hospital, Boston, MA, USA
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Lennerz JK, Salgado R, Kim GE, Sirintrapun SJ, Thierauf JC, Singh A, Indave I, Bard A, Weissinger SE, Heher YK, de Baca ME, Cree IA, Bennett S, Carobene A, Ozben T, Ritterhouse LL. Diagnostic quality model (DQM): an integrated framework for the assessment of diagnostic quality when using AI/ML. Clin Chem Lab Med 2023; 61:544-557. [PMID: 36696602 DOI: 10.1515/cclm-2022-1151] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Accepted: 01/13/2023] [Indexed: 01/26/2023]
Abstract
BACKGROUND Laboratory medicine has reached the era where promises of artificial intelligence and machine learning (AI/ML) seem palpable. Currently, the primary responsibility for risk-benefit assessment in clinical practice resides with the medical director. Unfortunately, there is no tool or concept that enables diagnostic quality assessment for the various potential AI/ML applications. Specifically, we noted that an operational definition of laboratory diagnostic quality - for the specific purpose of assessing AI/ML improvements - is currently missing. METHODS A session at the 3rd Strategic Conference of the European Federation of Laboratory Medicine in 2022 on "AI in the Laboratory of the Future" prompted an expert roundtable discussion. Here we present a conceptual diagnostic quality framework for the specific purpose of assessing AI/ML implementations. RESULTS The presented framework is termed diagnostic quality model (DQM) and distinguishes AI/ML improvements at the test, procedure, laboratory, or healthcare ecosystem level. The operational definition illustrates the nested relationship among these levels. The model can help to define relevant objectives for implementation and how levels come together to form coherent diagnostics. The affected levels are referred to as scope and we provide a rubric to quantify AI/ML improvements while complying with existing, mandated regulatory standards. We present 4 relevant clinical scenarios including multi-modal diagnostics and compare the model to existing quality management systems. CONCLUSIONS A diagnostic quality model is essential to navigate the complexities of clinical AI/ML implementations. The presented diagnostic quality framework can help to specify and communicate the key implications of AI/ML solutions in laboratory diagnostics.
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Affiliation(s)
- Jochen K Lennerz
- Department of Pathology, Massachusetts General Hospital/Harvard Medical, Boston, MA, USA
| | - Roberto Salgado
- Department of Pathology, GZA-ZNA Hospitals, Antwerp, Belgium
- Division of Research, Peter Mac Callum Cancer Centre, Melbourne, Australia
| | - Grace E Kim
- Department of Pathology, University of California San Francisco, San Francisco, CA, USA
| | | | - Julia C Thierauf
- Department of Pathology, Massachusetts General Hospital/Harvard Medical, Boston, MA, USA
- Department of Otorhinolaryngology, Head and Neck Surgery, German Cancer Research Center (DKFZ), Heidelberg University Hospital and Research Group Molecular Mechanisms of Head and Neck Tumors, Heidelberg, Germany
| | - Ankit Singh
- Department of Pathology, Massachusetts General Hospital/Harvard Medical, Boston, MA, USA
| | - Iciar Indave
- European Monitoring Centre for Drugs and Drug Addiction (EMCDDA), Lisbon, Portugal
| | - Adam Bard
- Department of Pathology, Massachusetts General Hospital/Harvard Medical, Boston, MA, USA
| | | | - Yael K Heher
- Department of Pathology, Massachusetts General Hospital/Harvard Medical, Boston, MA, USA
| | | | - Ian A Cree
- International Agency for Research on Cancer (IARC), World Health Organization, Lyon, France
| | - Shannon Bennett
- Department of Laboratory Medicine and Pathology (DLMP), Mayo Clinic, Rochester, MN, USA
| | - Anna Carobene
- IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Tomris Ozben
- Medical Faculty, Dept. of Clinical Biochemistry, Akdeniz University, Antalya, Türkiye
- Medical Faculty, Clinical and Experimental Medicine, Ph.D. Program, University of Modena and Reggio Emilia, Modena, Italy
| | - Lauren L Ritterhouse
- Department of Pathology, Massachusetts General Hospital/Harvard Medical, Boston, MA, USA
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Stuart LD, Torous VF, Chen Y, Pitman MB, Heher YK. Diagnostic error, interlaboratory communication, and resource management in cytopathology-surgical pathology collaboration: A 58-year-old woman with metastatic disease of unknown primary. Cancer Cytopathol 2023; 131:75-77. [PMID: 35969096 DOI: 10.1002/cncy.22635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2022] [Accepted: 07/13/2022] [Indexed: 02/04/2023]
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Harris CK, Darrell CM, VanderLaan PA, Heher YK. Patient-facing communication for cytopathologists: A framework for disclosing diagnostic error. Cancer Cytopathol 2023; 131:10-18. [PMID: 35904882 DOI: 10.1002/cncy.22627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 06/17/2022] [Accepted: 06/21/2022] [Indexed: 01/04/2023]
Abstract
Medical errors are a major source of harm to patients. Regulatory bodies mandate and patient safety experts advocate the disclosure of medical errors to patients to promote transparency and to create accountability for improving health care processes. Although pathologists regularly report errors-either to pathology or clinical colleagues or via internal safety reporting systems-few pathologists directly disclose those errors to patients. Yet many pathologists are interested in participating in the direct disclosure of medical errors to patients and may even be mandated to do so. When surveyed on why they do not directly disclose errors to patients, pathologists commonly cite a lack of confidence and a lack of training. Another barrier cited is the lack of a preexisting relationship between the pathologist and the patient. With respect to this last barrier, cytopathologists have a distinct advantage over surgical or clinical pathologists, as many cytopathologists regularly interact with and develop a rapport with patients when they are performing fine-needle aspiration (FNA) procedures. To improve the safety culture in pathology, direct error disclosure practices must be developed, supported, and strengthened. It is critical for cytopathologists to be comfortable with disclosing errors to patients. Being comfortable with disclosing an error, however, requires training, practice, and advance reflection. Using a practical, case-based format centered around FNA examples, this article addresses how to disclose a medical error to a patient. It provides a framework, heuristic principles, and structured conversation systems and talking points to guide the inexperienced pathologist to find his or her voice in a challenging disclosure conversation.
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Affiliation(s)
- Cynthia K Harris
- Department of Pathology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Caitlin M Darrell
- Department of Pathology, Advocate Health Care, Oak Lawn, Illinois, USA
| | - Paul A VanderLaan
- Department of Pathology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA
| | - Yael K Heher
- Department of Pathology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
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Yamamoto T, Pearson DS, Ababneh EI, Harris C, Nissaisorakarn P, Mahowald GK, Heher YK, Elias N, Markmann JF, Lewis GD, Riella LV. Case report: Successful simultaneous heart-kidney transplantation across a positive complement-dependent cytotoxic crossmatch. Front Nephrol 2022; 2:1047217. [PMID: 37675007 PMCID: PMC10479575 DOI: 10.3389/fneph.2022.1047217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Accepted: 11/11/2022] [Indexed: 09/08/2023]
Abstract
Preformed donor-specific antibodies are associated with a higher risk of rejection and worse graft survival in organ transplantation. However, in heart transplantation, the risk and benefit balance between high mortality on the waiting list and graft survival may allow the acceptance of higher immunologic risk donors in broadly sensitized recipients. Transplanting donor-recipient pairs with a positive complement dependent cytotoxic (CDC) crossmatch carries the highest risk of hyperacute rejection and immediate graft loss and is usually avoided in kidney transplantation. Herein we report the first successful simultaneous heart-kidney transplant with a T- and B-cell CDC crossmatch positive donor using a combination of rituximab, intravenous immunoglobulin, plasmapheresis, bortezomib and rabbit anti-thymocyte globulin induction followed by eculizumab therapy for two months post-transplant. In the year following transplantation, both allografts maintained stable graft function (all echocardiographic left ventricular ejection fractions ≥ 65%, eGFR>60) and showed no histologic evidence of antibody-mediated rejection. In addition, the patient has not developed any severe infections including cytomegalovirus or BK virus infection. In conclusion, a multitarget immunosuppressive regimen can allow for combined heart/kidney transplantation across positive CDC crossmatches without evidence of antibody-mediated rejection or significant infection. Longer follow-up will be needed to further support this conclusion.
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Affiliation(s)
- Takayuki Yamamoto
- Center for Transplantation Sciences, Massachusetts General Hospital/Harvard Medical School, Boston, MA, United States
- Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, MA, United States
| | - Daniel S. Pearson
- Histocompatibility Laboratory, Department of Pathology, Massachusetts General Hospital, Boston, MA, United States
- Department of Pathology, Massachusetts General Hospital, Boston, MA, United States
| | - Emad I. Ababneh
- Department of Pathology, Massachusetts General Hospital, Boston, MA, United States
| | - Cynthia Harris
- Department of Pathology, Massachusetts General Hospital, Boston, MA, United States
| | - Pitchaphon Nissaisorakarn
- Center for Transplantation Sciences, Massachusetts General Hospital/Harvard Medical School, Boston, MA, United States
- Division of Nephrology, Massachusetts General Hospital/Harvard Medical School, Boston, MA, United States
| | - Grace K. Mahowald
- Center for Transplantation Sciences, Massachusetts General Hospital/Harvard Medical School, Boston, MA, United States
- Histocompatibility Laboratory, Department of Pathology, Massachusetts General Hospital, Boston, MA, United States
- Department of Pathology, Massachusetts General Hospital, Boston, MA, United States
| | - Yael K. Heher
- Center for Transplantation Sciences, Massachusetts General Hospital/Harvard Medical School, Boston, MA, United States
- Department of Pathology, Massachusetts General Hospital, Boston, MA, United States
| | - Nahel Elias
- Center for Transplantation Sciences, Massachusetts General Hospital/Harvard Medical School, Boston, MA, United States
- Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, MA, United States
| | - James F. Markmann
- Center for Transplantation Sciences, Massachusetts General Hospital/Harvard Medical School, Boston, MA, United States
- Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, MA, United States
| | - Gregory D. Lewis
- Center for Transplantation Sciences, Massachusetts General Hospital/Harvard Medical School, Boston, MA, United States
- Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, MA, United States
| | - Leonardo V. Riella
- Center for Transplantation Sciences, Massachusetts General Hospital/Harvard Medical School, Boston, MA, United States
- Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, MA, United States
- Division of Nephrology, Massachusetts General Hospital/Harvard Medical School, Boston, MA, United States
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Harris CK, Pyden A, Onken AM, Yarsky B, Hayne C, Glickman J, Heher YK. Prioritizing Patient Safety and Minimizing Waste: Institutional Review of Cases and a Proposed Process for Designing a Surgical Pathology Gross-Only Examination Policy. Am J Clin Pathol 2022; 158:598-603. [PMID: 35972436 DOI: 10.1093/ajcp/aqac093] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 06/17/2022] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVES Gross-only examination policies vary widely across pathology departments. Several studies-particularly a College of American Pathologists' Q-Probes study-have looked at the variations in gross-only policies, and even more studies have addressed the (in)appropriateness of certain specimen types for gross-only examination. Few, if any, studies have tackled the important task of how to revise and safely implement a new gross-only examination protocol, especially in collaboration with clinical colleagues. METHODS We reviewed the grossing protocols from three anatomic pathology centers to identify common gross-only specimen types. We compiled an inclusive list of any specimen types that appeared on one or more centers' lists. We performed a retrospective review of the gross and microscopic diagnoses for those specimen types to determine if any diagnoses of significance would have been missed had that specimen been processed as a gross-only. RESULTS We reviewed 940 cases among 13 specimen types. For 7 specimen types, the gross diagnoses provided equivalent information to the microscopic diagnoses. For 6 specimen types, microscopic diagnoses provided clinically meaningful information beyond what was captured in the gross diagnoses. CONCLUSIONS To improve the value of care provided, pathology departments should conduct internal reviews and consider transitioning specimen types to gross-only when safe.
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Affiliation(s)
- Cynthia K Harris
- Department of Pathology, Massachusetts General Hospital, Boston, MA, USA
| | - Alexander Pyden
- Department of Pathology, Division of Pathology and Laboratory Medicine, Lahey Hospital & Medical Center, Burlington, MA, USA
| | - Allison M Onken
- Department of Pathology, Brigham and Women's Hospital, Boston, MA, USA
| | - Benjamin Yarsky
- Division of Quality and Performance Improvement, Children's Hospital of Los Angeles, Los Angeles, CA, USA
| | - Cynthia Hayne
- Department of Pathology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Jonathan Glickman
- Department of Pathology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Yael K Heher
- Department of Pathology, Massachusetts General Hospital, Boston, MA, USA
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Torous VF, Pitman MB, Heher YK. The value of monitoring amended reports in cytopathology quality programs: A biennial review. Cancer Cytopathol 2022; 130:860-871. [PMID: 35666141 DOI: 10.1002/cncy.22607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2022] [Revised: 05/14/2022] [Accepted: 05/16/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Quality and safety are the foundation of the practice of cytopathology. Review of key performance indicator (KPI) data can shine a light on laboratory vulnerabilities and potential areas for targeted improvement. The rate and content of amendment reports is a frequently monitored KPI in anatomic pathology, but few have studied its value in cytopathology. The goal of this study was to examine the frequency, classification, and outcome of amendments for a large cytopathology laboratory. METHODS All amendment reports issued for cases during a 2-year period from July 2019 to June 2021 were included in the study. Amendments were classified into three error type root causes: Specimen Identification Error, General Report Defects, and Diagnostic Error. RESULTS A total of 202 amendment reports were issued equating to a rate of 0.275%. A total of 83 (41.1%) were gynecologic cases and 119 (58.9%) were nongynecologic cases. Within the gynecologic cases, 13 (15.7%) cases were due to Specimen Identification Error, 13 (15.7%) cases were due to Diagnostic Error, and 57 (68.7%) cases were due to General Report Defects. Within the nongynecologic cases, 15 (12.6%) cases were due to Specimen Identification Error, 30 (25.2%) cases were due to General Report Defects, and 74 (62.2%) cases were due to Diagnostic Error with 32 of these due to true diagnostic change. Discovery methods included following re-review after additional clinical information was provided, reinterpretation after additional ancillary testing was performed, or conference review. There was no correlation with years in practice. CONCLUSIONS Studying amendment reports is an underrecognized and valuable quality assurance tool. Amendments can help provide information about types of errors, monitor laboratory processes, and help guide quality improvement endeavors.
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Affiliation(s)
- Vanda F Torous
- Department of Pathology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Martha B Pitman
- Department of Pathology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Yael K Heher
- Department of Pathology, Massachusetts General Hospital, Boston, Massachusetts, USA
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Harris CK, Chen Y, Jensen KC, Hornick JL, Kilfoyle C, Lamps LW, Heher YK. Towards high reliability in national pathology education: Evaluating the United States and Canadian Academy of Pathology educational product. Acad Pathol 2022; 9:100048. [PMID: 36061265 PMCID: PMC9429554 DOI: 10.1016/j.acpath.2022.100048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 06/15/2022] [Accepted: 06/26/2022] [Indexed: 11/22/2022] Open
Abstract
The United States and Canadian Academy of Pathology (USCAP) leadership undertook a high level, global review of educational product outcomes data using high reliability organization (HRO) principles: preoccupation with failure; reluctance to simplify; sensitivity to operations; commitment to resilience; and deference to expertise. HRO principles have long been applied to fields such as aviation, nuclear power, and more recently to healthcare, yet they are rarely applied to the field that underpins these—and many other—complex systems: education. While errors in education are less calamitous than in air travel or healthcare delivery, USCAP's educational products impact over 15,000 learners a year, and thus have important implications for the future practice of pathology. Here we report USCAP's experiences using HRO principles to evaluate our keystone educational product, the “USCAP Short Course.” Following this novel method of data review, USCAP leadership was able to better understand diverse learner needs based on practice venue, training level, and course topic. Unexpected lessons included the identification of specifically challenging educational topics, such as molecular pathology, and a need to focus more resources on emerging fields such as quality and patient safety. The results allow USCAP to assess educational product performance using HRO tools, and provide strong data-driven decision support for future national pathology education strategy.
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10
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Weiss VL, Heher YK, Seegmiller A, VanderLaan PA, Nishino M. All in for patient safety: a team approach to quality improvement in our laboratories. J Am Soc Cytopathol 2022; 11:87-93. [PMID: 34996748 PMCID: PMC8885884 DOI: 10.1016/j.jasc.2021.12.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Revised: 12/05/2021] [Accepted: 12/06/2021] [Indexed: 01/21/2023]
Abstract
Patient safety and quality improvement initiatives are integral parts of every cytopathology laboratory. The need to revisit our approaches to patient safety are essential in light of the expanding test menu, ancillary studies, comprehensive diagnostic reports, and emergence of new technologies for augmenting cytologic diagnosis. Our interview with Drs. Yael Heher, Adam Seegmiller, and Paul VanderLaan explores recent developments that have shaped their perspectives in patient safety, test usage, and laboratory quality. The practical strategies presented provide tools for enhanced patient safety and improved outcomes in a new era of ancillary and molecular testing and standardized reporting in the cytopathology laboratory.
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Affiliation(s)
- Vivian L. Weiss
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University School of Medicine, Nashville, TN,Correspondence: Vivian Weiss, M.D. Ph.D., Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, 1161 21st Ave. S., MCN C-3321, Nashville, TN 37232, Phone: 615-875-3002, , Michiya Nishino, M.D. Ph.D., Department of Pathology, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02115, Phone: 617-667-5731,
| | - Yael K. Heher
- Department of Pathology, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Adam Seegmiller
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University School of Medicine, Nashville, TN
| | - Paul A. VanderLaan
- Department of Pathology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA
| | - Michiya Nishino
- Department of Pathology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts.
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Chen Y, VanderLaan PA, Heher YK. Using the Model for Improvement and Plan-Do-Study-Act to effect SMART change and advance quality. Cancer Cytopathol 2020; 129:9-14. [PMID: 32749742 DOI: 10.1002/cncy.22319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 06/04/2020] [Indexed: 11/12/2022]
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Abstract
Growing regulatory burdens, payment model changes, and increased complexity in laboratory medicine have contributed to an increased reliance on reference laboratories. Although reference laboratories often offer rapid, low cost, high quality testing, outsourcing laboratory tests can create quality and patient safety vulnerabilities particularly in the pre-analytic and post-analytic phases of the test cycle. Disconnects in governance, policy, and information technology between the reference laboratory and the referring provider conspire to increase risk. Laboratory leaders seeking to reduce risk and improve quality must ensure clear and collaborative oversight, monitor meaningful quality metrics, and integrate feedback from ordering providers.
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13
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Affiliation(s)
- Yael K Heher
- Department of Pathology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
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14
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Heher YK, Chen Y, VanderLaan PA. Pre-analytic error: A significant patient safety risk. Cancer Cytopathol 2019; 126 Suppl 8:738-744. [PMID: 30156766 DOI: 10.1002/cncy.22019] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Revised: 04/19/2018] [Accepted: 04/23/2018] [Indexed: 12/12/2022]
Abstract
Ancillary testing in cytopathology has grown dramatically over the past decade, enhancing the clinical value of cytology specimens obtained via minimally invasive methods. However, a complex testing landscape brings with it new and emerging risks to patient safety. Recognition of complicated systems issues as well as shared responsibility in process ownership can help to minimize safety risks. Because pre-analytic factors account for the majority of errors in pathology, attention to operational steps (test ordering, specimen collection, specimen transport, specimen accessioning, and specimen processing) is critical for successful quality improvement programs. With increasing technical costs and complexity of many ancillary molecular tests, a growing trend toward send-out testing to centralized reference laboratories poses additional patient safety risks. Given these new realities in cytopathology ancillary testing, a collaborative, team-based approach with all process stakeholders is needed to improve pre-analytic processes, reduce error risk, and enhance patient safety.
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Affiliation(s)
- Yael K Heher
- Department of Pathology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
| | - Yigu Chen
- Department of Pathology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
| | - Paul A VanderLaan
- Department of Pathology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
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Samulski TD, Chen YV, Scanga LR, Heher YK. Cytology specimen contamination leads to a false-positive surgical pathology diagnosis: Root cause analysis and patient safety lessons. Cancer Cytopathol 2019; 127:618-620. [PMID: 31174232 DOI: 10.1002/cncy.22144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Chen Y, Anderson KR, Xu J, Goldsmith JD, Heher YK. Frozen-Section Checklist Implementation Improves Quality and Patient Safety. Am J Clin Pathol 2019; 151:607-612. [PMID: 30892600 DOI: 10.1093/ajcp/aqz009] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVES An intraoperative consultation (IOC) checklist was developed and implemented aimed at standardizing slide labeling and monitoring metrics central to quality and safety in surgical pathology. DESIGN Data were collected for all IOC cases over a 9-month period. Slide labeling defect rates and IOC turnaround time (TAT) were recorded and compared for the pre- and postimplementation periods. RESULTS In total, 839 IOC cases were analyzed. Preintervention slide labeling showed that 85% of cases contained at least one defect (n = 565). Postintervention data revealed that 27% of cases contained at least one defect (n = 274). The improvement was statistically significant (P < .001). Mean TAT was 21.6 minutes preintervention vs 23.2 minutes postintervention, and the change was insignificant (P = .071). CONCLUSIONS The implementation of a standardized IOC reduced slide labeling error. This improvement did not affect mean TAT and may have the increased quality of IOC TAT data reporting. Other metrics affecting patient safety and quality were monitored and standardized.
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Affiliation(s)
- Yigu Chen
- Beth Israel Deaconess Medical Center, Pathology, Boston, MA
| | | | - Jia Xu
- Beth Israel Deaconess Medical Center, Pathology, Boston, MA
| | - Jeffrey D Goldsmith
- Beth Israel Deaconess Medical Center, Pathology, Boston, MA
- Boston Children’s Hospital, Pathology, Boston, MA
| | - Yael K Heher
- Beth Israel Deaconess Medical Center, Pathology, Boston, MA
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Stravitz PE, Cibas ES, Heher YK. Targeting specimen misprocessing safety events with failure modes and effects analysis. Cancer Cytopathol 2019; 127:213-217. [PMID: 30689294 DOI: 10.1002/cncy.22096] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Chen Y, VanderLaan PA, Heher YK. False positive diagnosis of lymph node metastases in a 34-year-old woman with a history of extraskeletal myxoid chondroscarcoma: A root cause analysis. Cancer Cytopathol 2018; 127:69-71. [PMID: 30394675 DOI: 10.1002/cncy.22044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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VanderLaan PA, Chen Y, DiStasio M, Rangachari D, Costa DB, Heher YK. Molecular Testing Turnaround Time in Non–Small-Cell Lung Cancer: Monitoring a Moving Target. Clin Lung Cancer 2018; 19:e589-e590. [DOI: 10.1016/j.cllc.2018.04.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Accepted: 04/24/2018] [Indexed: 10/17/2022]
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Heher YK, Chen Y. Process mapping: A cornerstone of quality improvement. Cancer Cytopathol 2017; 125:887-890. [PMID: 29165909 DOI: 10.1002/cncy.21946] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Accepted: 10/09/2017] [Indexed: 11/08/2022]
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DiStasio M, Chen Y, Rangachari D, Costa DB, Heher YK, VanderLaan PA. Molecular Testing Turnaround Time for Non–Small Cell Lung Cancer in Routine Clinical Practice Confirms Feasibility of CAP/IASLC/AMP Guideline Recommendations: A Single-center Analysis. Clin Lung Cancer 2017; 18:e349-e356. [DOI: 10.1016/j.cllc.2017.03.001] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Revised: 02/21/2017] [Accepted: 03/06/2017] [Indexed: 11/29/2022]
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22
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Heher YK, Chen Y, VanderLaan PA. Measuring and assuring quality performance in cytology: A toolkit. Cancer Cytopathol 2017; 125:502-507. [DOI: 10.1002/cncy.21831] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2016] [Revised: 12/14/2016] [Accepted: 01/03/2017] [Indexed: 01/21/2023]
Affiliation(s)
- Yael K. Heher
- Department of Pathology, Beth Israel Deaconess Medical Center; Harvard Medical School; Boston Massachusetts
| | - Yigu Chen
- Department of Pathology, Beth Israel Deaconess Medical Center; Harvard Medical School; Boston Massachusetts
| | - Paul A. VanderLaan
- Department of Pathology, Beth Israel Deaconess Medical Center; Harvard Medical School; Boston Massachusetts
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Heher YK, Chen Y, Pyatibrat S, Yoon E, Goldsmith JD, Sands KE. Achieving High Reliability in Histology: An Improvement Series to Reduce Errors. Am J Clin Pathol 2016; 146:554-560. [PMID: 28430956 DOI: 10.1093/ajcp/aqw148] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Despite sweeping medical advances in other fields, histology processes have by and large remained constant over the past 175 years. Patient label identification errors are a known liability in the laboratory and can be devastating, resulting in incorrect diagnoses and inappropriate treatment. The objective of this study was to identify vulnerable steps in the histology workflow and reduce the frequency of labeling errors (LEs). METHODS In this 36-month study period, a numerical step key (SK) was developed to capture LEs. The two most prevalent root causes were targeted for Lean workflow redesign: manual slide printing and microtome cutting. The numbers and rates of LEs before and after interventions were compared to evaluate the effectiveness of interventions. RESULTS Following the adoption of a barcode-enabled laboratory information system, the error rate decreased from a baseline of 1.03% (794 errors in 76,958 cases) to 0.28% (107 errors in 37,880 cases). After the implementation of an innovative ice tool box, allowing single-piece workflow for histology microtome cutting, the rate came down to 0.22% (119 errors in 54,342 cases). CONCLUSIONS The study pointed out the importance of tracking and understanding LEs by using a simple numerical SK and quantified the effectiveness of two customized Lean interventions. Overall, a 78.64% reduction in LEs and a 35.28% reduction in time spent on rework have been observed since the study began.
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Affiliation(s)
| | | | - Sergey Pyatibrat
- Department of Pathology and Laboratory Medicine, Ottawa Hospital, Ottawa, Canada
| | | | - Jeffrey D Goldsmith
- From the Department of Pathology
- Department of Pathology, Children's Hospital Boston, Boston, MA
| | - Kenneth E Sands
- Department of Healthcare Quality, Beth Israel Deaconess Medical Center, Boston, MA
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