Playing it safe - new book takes
  aim at AP errors

May 2005
Feature Story

New chapters on reducing and preventing errors in surgical pathology and managing quality in histology and immunohistochemistry represent the major updates in the CAP’s new book, Quality Management in Anatomic Pathology: Promoting Patient Safety Through Systems Improvement and Error Reduction, released this month.

"Quality of medical and laboratory services and patient safety issues have really come to the fore in recent years," says Lawrence J. Burgart, MD, of Mayo Clinic, Rochester, Minn., who chairs the CAP’s Surgical Pathology Committee. "We’ve taken this opportunity to expand all of the areas that deal with patient safety issues. In addition, immunohistochemistry has become a much more prevalent part of laboratory practice, and material has been added in that area. It’s a key resource for practicing pathologists."

The book is the latest version of the differently titled Quality Improvement in Anatomic Pathology, released in 2001, and some of the chapters are similar, says Patrick L. Fitzgibbons, MD, of St. Jude Medical Center, Fullerton, Calif., who co-edited the volume with Raouf Nakhleh, MD, of St. Luke’s Hospital/Mayo Clinic Jacksonville in Florida. "We changed the name of the book to reflect a different emphasis," Dr. Fitzgibbons says. "That’s one thing I was worried about: that people might think it was a completely different book."

The revisions do significantly change the text’s approach to error reduction, advocating a systems-based strategy that stays focused on the big picture, says Dr. Nakhleh, who wrote the new chapter on error reduction in surgical pathology.

"The traditional view of errors and problems in the laboratory is to blame individuals or look at problems in isolation, whereas if you’re going to approach it from a quality assurance and quality improvement perspective, you have to look at how things interact," he says. "You critically look at how all the parts interact even though they appear to be removed from one another." Make sure that fixes on one end do not introduce problems on the other end, he says. "Maybe you’re trying to fix your car radio, but that’s causing a short that shuts down the engine."

In addition to infusing that big-picture thinking into the manual, Dr. Nakhleh says he and others who worked on Quality Management could see unmet needs despite the "many positive comments" they had received about the previous edition.

"People wanted more answers on how to reduce errors," he says. "And there were areas not being addressed. For instance, we didn’t focus much [previously] on the specifics of histology and immunohistochemistry. We needed to have some solid footing from a quality assurance perspective in those areas."

The editors also tried to find opportunities to give time-pressed readers the ability to reference specific problems quickly through checklists and tables rather than have to wade through text, Dr. Nakhleh says.

"We have gone out of our way to try to make this user-friendly," he says, citing as an example an updated chapter on regulatory information that reflects the most recent CAP Laboratory Accreditation Program checklists. "If you wanted to do something in quality assurance, you could very quickly use this book and come up with a checklist or a table that you could incorporate into your daily work.

"We hope they can use these as guidelines in doing quality assurance in their own laboratories," he adds. "At another level, we’ve tried to incorporate as many references into this book as possible, so that even if we don’t have the specifics there ... the reference material may be helpful in finding the answers."

The new chapter on preventing and reducing errors in surgical pathology draws from successful strategies in other corners of the medical field and from industry at large, Dr. Nakhleh says. "Certainly there are some industries that are far more advanced in error reduction than medicine in general and pathology," he says.

The chapter’s systems approach does not represent business-as-usual for pathologists, says Dr. Fitzgibbons, who likens it to Six Sigma. "It’s a more structured approach to how to design workflow," he says. "It’s the direction we need to go, at least for anatomic pathology: How do we identify where errors could occur? [Dr. Nakhleh] tried to present the kinds of concepts you have to think about when you’re designing systems, and what steps need to be done.

"It’ll be interesting for me to see how people react to it," he adds. "It’s not something that pathologists are used to thinking about."