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A matter of interconnectivity
It is not in the manner of how you build the boat, but how you affect
the wave. — Leland Kaiser, PhD
June 2003
Paul A. Raslavicus, MD
The Centers for Disease Control and Prevention recently convened a conference of
laboratory professionals from academia, hospitals, the independent
clinical laboratory sector, professional associations, and government
in a thoughtful program titled Quality Institute Conference 2003:
Making the Laboratory a Key Partner in Patient Safety. It was an
intellectually satisfying session in which the contributions of
pathologists and of the College to patient safety and improvement
in care quality through cancer protocols and other programs were
consistently favorably cited. Our clinical colleagues spoke repeatedly
about how difficult it is for the front-line physician to keep up
with progress in laboratory medicine. To avoid diagnostic errors,
they know they need to tap the knowledge base that our specialty
possesses. They urged us to work in close partnership with them
by contributing our unique knowledge base of the medical laboratory.
Not that we have not known of this need for many a year! It was
in 1981 that George Lundberg, MD, defined brain-to-brain turnaround
time as the critical full cycle in patient care. “Brain-to-brain”
views a laboratory test as an event that begins when the clinician
starts to think about what tests to order and ends when he or she
has taken action on the results. An error at any point within this
critical path, which includes the cerebrum of the attending, can
compromise patient welfare and must be avoided.
Pathologists and other professionals in the laboratory have been
the leaders in designing the quality assurance systems required
to root out error. We have worked hard for nearly 50 years to improve
the testing process, and we have now come to the time when error
in analysis is least likely to be the cause of an erroneous result.
Most “laboratory error” occurs outside the laboratory
analysis, in the preanalytic (procedural) and postanalytic (communication)
phases of the brain-to-brain cycle. Procedural errors in patient
and specimen preparation, identification, transportation, handling,
and accession are not uncommon. Communication-related problems most
often relate to report delivery, format, clarity, timeliness, and
integration of information. Add to these the pitfalls inherent in
a potentially inadequate knowledge base of the physician who is
ordering and interpreting the tests and you have myriad failure
possibilities.
Some 15 years ago Peter Howanitz, MD, and Paul Bachner, MD, used
their bold imaginations to launch the Q-Probes program in which
many of you participate. Later, Richard Zarbo, MD, introduced Q-Tracks,
and over the years, dozens of pathologists designed and analyzed
the 122 studies of both programs. Through your efforts in hundreds
of laboratories we have identified the areas in the pre- and postanalytic
phases of testing that are especially vulnerable to affecting the
quality of care. We have demonstrated that we practice in a world
of medicine in which everything is interconnected in an ever widening
scope of systems within systems within systems. We were the first
to take the giant step that identified and publicized the trigger
points that have high potential to harm patients. We should be proud
of the leadership position we have achieved.
But who has studied the neuronal synapses of the attending physician
so critical in the brain-to-brain quality equation? Speakers at
the CDC conference told of the failure of our clinical colleagues
to understand the complexities of laboratory medicine and to turn
laboratory data into correct information for decision-making. All
of our efforts in the clinical lab will be for naught if tests are
ordered and interpreted incorrectly or ineffectively. To prevent
this failure in interconnectivity, we must educate and communicate.
Yes, these are generalizations, but consider the following:
- How many medical
schools present to their students pathology and laboratory medicine
as disciplines in their own right, with their own body of knowledge,
operating constraints, and intellectual challenges?
- How many surgical
residency programs require reasonable familiarity with the discipline
of surgical pathology, leading to an understanding of its limitations
and intellectual challenges?
- How many internists
are exposed in their training to the challenges of laboratory
medicine, such as the variation inherent in methods and the influence
of drugs on test results? How many truly comprehend the ravages
of disease on the human body as seen at autopsy?
- How many pathologists
are sufficiently trained in the complexities of laboratory medicine
to feel comfortable being consultants to their clinical colleagues
who are often in the dark on what the findings mean, let alone
how to integrate multiple laboratory data points into a diagnostic
algorithm? How many of us understand the constraints operating
in the direct patient care environment and are willing to help,
or are capable of helping?
The combined
effect of these realities is that we as physicians frequently
can hardly understand one another or how communication among us
is so necessary for patients’ sake. The lack of understanding
by our clinical colleagues of the body of knowledge that is laboratory
medicine has stifled the appropriate use of the expertise of the
well-trained and dedicated clinical pathologist. Similarly, the
lack of reward systems for working in laboratory medicine has
stifled the recruitment of physicians into clinical pathology.
Given that laboratory-based information influences so much of
medical decision-making, we have paid a terrible price.
At this CDC conference, those leading the patient safety movement
called for all of us to leave our laboratories and to help our
clinical colleagues understand and more appropriately use the
tools we provide for them. We can lead by providing educational
conferences for our medical staffs, by participating in outcomes
measures and patient safety activities in our hospitals, and by
being involved in the clinic and on bed rounds. We must also encourage
the use of our knowledge through consultations. Vanguard hospitals
and foresighted pathologists are doing precisely that. Institutions
such as the Massachusetts General Hospital know that greater use
of clinical pathology consultation improves patient outcomes and
reduces costs. Using his 24/7 laboratory SWAT team, Michael Laposata,
MD, PhD, has proven the value of the clinical pathologist at the
MGH in the expeditious, cost-effective, error-reducing, length-of-stay-improving
consultations in coagulation, therapeutic drug monitoring, toxicology,
and other specialized areas.
The interconnectedness of our work to patient care and safety
signifies a larger role for the clinical pathologist in years
to come. But we cannot do what is needed without our technologist
colleagues, our phlebotomists, our colleagues in independent laboratories,
and nurses. Yes, even patients are part of the interconnectivity
paradigm. They need to share information about themselves, from
their clinical symptomatology to their social history. Shared
responsibility for patient safety means more emphasis on communication—patient-to-physician,
pathologist-to-clinician, technologist-to-pathologist, brain-to-brain.
As speakers at the conference said, only then will we be able
to do things right—and do the right things. In a systems
world, interconnectivity rules.
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