Difference between revisions of "Quality"

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Quality issues are examined a number of different ways, e.g. root cause analysis, failure mode and effects analysis (FMEA).
Quality issues are examined a number of different ways, e.g. root cause analysis, failure mode and effects analysis (FMEA).


A common way to break down error analysis is:
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Revision as of 15:01, 21 December 2011

Quality, in pathology, has got a lot of attention lately because there have been high profile screw-ups that lead to significant harm.[1]

Analysis

Quality issues are examined a number of different ways, e.g. root cause analysis, failure mode and effects analysis (FMEA).

A common way to break down error analysis is:

 
 
 
 
 
 
 
 
Errors in pathology
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Pre-analytical errors
 
 
Analytical errors
 
 
Post-analytical errors

Error reduction

Various strategies can be employed:[2]

  • Training of staff - on error handling.
  • Computer order entry.
    • Avoid duplication fatigue.
    • Quick correlation with several identifying features.
      • Full name, sex, date of birth -- these all appear when one opens a case.
  • Barcode use.
    • Avoid transcription errors.
  • Clinical information entry required.
    • Allow correlation with test.
      • The interpretation may differ if the history says "screening coloscopy" versus "large cecal mass, anemia and weight loss".

Other strategies:

  • Statistical process control.

Sources of error

  • "Human error".
    • Training.
    • Work flow.
  • Process gaps.
    • Process control.
    • Lack of redundancy.

Biopsy size

Very small tissue fragments are associated with a decreased diagnostic yield and an increased diagnostic uncertainty.

See also

References

  1. URL: http://www.attorneygeneral.jus.gov.on.ca/inquiries/goudge/index.html. Accessed on: 1 March 2011.
  2. Fabbretti, G. (Jun 2010). "Risk management: correct patient and specimen identification in a surgical pathology laboratory. The experience of Infermi Hospital, Rimini, Italy.". Pathologica 102 (3): 96-101. PMID 21171512.