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Difference between revisions of "Quality"
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==Analysis== | ==Analysis== | ||
===Overview=== | |||
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). | ||
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{{familytree/end}} | {{familytree/end}} | ||
===Failure-potential analysis=== | ====Failure-potential analysis==== | ||
Adapted from Ullman:<ref name=ullman>{{cite book |title=The mechanical design process |last= Ullman |first = David G. |authorlink= |coauthors= |year= 1997 |publisher= McGraw-Hill Companies Inc. |location= Toronto|isbn=0-07-065756-4 |page= |pages= |url= |accessdate=}}</ref> | Adapted from Ullman:<ref name=ullman>{{cite book |title=The mechanical design process |last= Ullman |first = David G. |authorlink= |coauthors= |year= 1997 |publisher= McGraw-Hill Companies Inc. |location= Toronto|isbn=0-07-065756-4 |page= |pages= |url= |accessdate=}}</ref> | ||
#Identify potential individual failures. | #Identify potential individual failures. | ||
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#Identify how the individual failures can arise. | #Identify how the individual failures can arise. | ||
#Identify the corrective action. | #Identify the corrective action. | ||
===Error analysis=== | |||
*Pathology errors happen any time from when the lab gets the specimen until after the report is isssued. | |||
When errors happen: | |||
*Work-up problem - where did it occur. | |||
*Talk to clinican - if it is a ''[[critical diagnosis]]'' contact most-responsible physician... if unreachable physician on-call for the most-responsible physician. | |||
*Talk to chief of pathology. | |||
*Incident report. | |||
*Reconstruct error. | |||
**Is there another error? (What it a specimen mix-up?) | |||
*Amend report(s). | |||
*Remedy source of error. | |||
Pre-analytic: | |||
*Container mix-up - pre-lab & in-lab. | |||
*Block mix-up. | |||
*Slide mix-up - labels wrong. | |||
*Poor quality slides (fixation, processing, staining). | |||
Analytic: | |||
*Interpretation wrong. | |||
**Difficult case. | |||
**Technical factors (quality of slides). | |||
Post-analytic: | |||
*Wrong case signed-out. | |||
*Filing problem. | |||
*Interpretation of report problem (poorly written, bad interpretation). | |||
==Error reduction== | ==Error reduction== | ||