Quality Issues
Critical Diagnoses in Anatomic Pathology
- General:
- Optimal
tissue preparation and processing
- Diagnostic
reports that are:
- Timely
- Complete
- Accurate
- Understandable
- Quality
Control (QC)
- Ongoing
evaluation of:
- Personnel
- Equipment
- Materials
- Prescribed
corrective actions
- Quality
Assurance (QA)
- Preanalytical
- Specimen
procurement
- Specimen
and patient identification
- Adequacy
of clinical history
- Transportation
- Accessioning
- Technical
handling of tissue preparations
- Specimen
fixation
- Histology
- Quality
of histologic sections
- Specimens
lost in processing
- Histology
turn around time (TAT)
- Block
labeling error rate
- Slide
labeling error rate
- Extraneous
tissue (pickups & floaters) rate
- Immunohistochemistry:
- Frequency
and causes of repeat stains
- Immunohistochemistry TAT
- Report
audit for integration of stains with morphologic diagnosis
- Annual
review of antibody inventory and frequency of use
- Enrollment
in external proficiency testing (ex. for Her2/neu)
- Analytical
- Cytology
screening:
- Prospective rescreening:
- Random rescreening (10%)
- Rapid
rescreening
- Directed
rescreening
- Intraoperative consultation
- Frozen-permanent
concordance
- Frozen
section TAT
- Final
diagnosis
- Peer
review (“bench-marking”) error rate
- 1.5%
cognitive error rate is common
- Cytology
/ histology correlation
- Review
of previous pathology material (ex. for new diagnosis of HSIL)
- Amendment
rate (1-3 / 1000 is acceptable)
- Rates
of ASCUS / SIL
- Prospective
case reviews
- Random
review (1-10%)
- Focused
review
- Specific
organ system
- Specific
malignancy type
- New
diagnosis of malignancy
- Prior
to a major surgical procedure
- Interdepartmental
conferences (e.g. tumour board)
- Intradepartmental
quality assurance conference
- Review
of previous pathology material
- Intradepartmental
review of material before the release to other institutions
- Standardized
reporting
- Postanalytical
- Medical
transcription
- Prompt
and thorough review of reports by pathologists
- Verification
errors during electronic signout or report
finalization
- Incomplete
reports
- Diagnostic
finding correlation with ancilliary studies
- Timely
delivery of reports to the clinical physicians
- Report
delivery errors
- Biopsy
TAT
- Large
specimen TAT
- Autopsy
report TAT
·
Preliminary
·
Final
§
Clinician satisfaction and
/ or complaints
- Continuous
quality improvement (CQI)
- Structuring
of an organized plan for effecting increasing quality in all aspects of
QC and QA
- Tools
for QA/QC
- Detailed, updated procedure manuals (SOPs)
- Scheduling
and documenting instrument maintenance (process charts)
- Review
of specimens from outside hospitals that accompany referral cases
- Regular
slide quality assessments
- Measurement
of interobserver agreement
- Cytologic-histologic correlations
- Frozen-permanent
correlations
- Mandatory
review by a second pathologist of any new diagnosis of malignancy
- Cross-sectional
reviews of percentage of diagnoses by a second observer in the same
practice group
- Referral
of a prescribed proportion of cases to an extramural consultant
- Evaluation
of diagnostic competency
- CAP
performance improvement program
- ASCP
CheckPath and CheckSample
- Synoptic
reporting
- Error
types:
- Change
in categorical interpretation (e.g. benign to malignant, malignant to
benign)
- False
positive
- False
negative
- Change
within the same category of interpretation (change in type of malignancy
- Change
in threshold (e.g. ADH vs DCIS, grading)
- Change
in margin status
- Change
in lymph node status
- Change
in information unrelated to the diagnosis
- Case
or patient misidentification
- Site
misidentification (right vs. left)
- Effect
of error on patient:
- No
harm or impact on patient care
- Slight
harm or impact on patient care
- Significant
harm or alteration of clinical management
- Types
of report changes:
- Amendment
– change in diagnosis
- Corrected
report – Change in information other than the diagnosis
- Addendum
– additional information, no changes to original report