common errors in histopathology laboratorycommon errors in histopathology laboratory

Specimen defects included five subtypes: lost specimens, specimens with inadequate sample volume or size, samples with absent or discrepant measurements, inadequately representative sampling, and samples with absent or inappropriate ancillary studies. Some cases of misinterpretations occur as a failure to perform special stains, such as Periodic acid-Schiff stain not done in cases of the nasal polyp with fungal hyphae. To date our community has made over 100 million downloads. The analytic phase includes errors in classification, false negative or positives, and in post-analytic phase, and they describe the defective reports (erroneous or missing nondiagnostic information, error in dictation or typing, report delivery and errors related to computer or format, transmission and upload error). PDF Practical Guide to Specimen Handling in Surgical Pathology The most commonly utilized is a classification in pre-analytical, analytical, and post-analytical phases, but we note that the errors can overlap between these categories. We describe four types of errors (defective identification, defective specimen, defective interpretation, and defective report), distributed according to the processing step in the laboratory. Steps to Better Grossing Geoffrey Rolls, BAppSc, FAIMS From patient to pathologist, preparing tissue specimens for histological examination requires care, skill and sound procedures. Clifford M. Chapman has held the position of Technical Director at Pathology Services, Children's Hospital Boston and StrataDx from 1983 to 2014. Patient Saf Surg. As expected, 98.5% of the errors were due to a lack of attention, and the majority had no consequences for the patient (88%). Over 40% of lab mistakes occur during the pre-analytical step, whereas only 7% occur during the testing itself. Distribution of errors according to the operating process phase and examples. The limited extent to which audit can be used to assess the performance of individual pathologists is also covered. Woolgar JA, Ferlito A, Devaney KO, Rinaldo A, Barnes L. Eur Arch Otorhinolaryngol. The International Collaboration on Cancer Reporting maintains the guidelines and all the necessary parameters in the histopathological report at http://www.iccr-cancer.org/datasets to guide clinical management, as well as to provide prognostic information for several cancers; the guidelines panel is a result of a six-week public consultation conducted by a Dataset Authoring Committee, with multidisciplinary experts. IMPREGNATION AND TISSUE EMBEDDING | Histopathology Notes - Paramedics World UNITED KINGDOM, Monique Freire Santana and Luiz Carlos de Lima Ferreira, Diagnostic errors and concordances in pathology. The result must be accurate, based on gold standards, and scientifically validated. The tissue floaters can be found in histology water baths and the slide stainers. In some cases, problems in the cutting, staining, or assembling of the slides can completely prevent an adequate diagnosis (Figures 1 and 2). A study carried out in Pennsylvania, in a teaching hospital with Pathology residency training, identified 491 errors. In many instances, merely implementing a system of barcode specimen tracking significantly reduced errors associated with misidentified samples; for instance, at the Henry Ford Hospital, there was a 92% decrease in slide misidentification and a 62% decrease in total misidentified cases after barcodes were applied to the workflow. Which Chemicals Do I Need to Test with My Labels, Customizing Lab Requisition Forms Enhances Sample Tracking in Diagnostic Labs, ChatGPT & the Growing Influence of AI in Science. Misinterpretation of histopathological results as an important risk The pathologic diagnosis depended on interpretative and subjective skills. Cases J. Licensee IntechOpen. One factor conferred to the increase in the number of medical errors is the excessive decentralization of patient care. Manage excessive workloads Though often impossible due to resource and budget constraints, excessive workloads should be kept to a minimum to ensure staff doesnt suffer from burnout, a type of severe stress that can directly impact the quality of work being done and impair your ability to stay focused. Patient and Sample Identification. HHS Vulnerability Disclosure, Help Surgical specimen identification errors: a new measure of quality in surgical care. Effectiveness of random and focused review in detecting surgical pathology error. Fluorescence detection, enumeration and characterization of single circulating cells in vivo: technology, applications and future prospects. Quality and safety aspects in histopathology laboratory. The highest values were related to diagnostic errors in melanomas (US$757,146; 95% false negatives), cervicovaginal cytology (US$686,599; 98% false negatives) and breast cancers (US$203,192, with the same proportion of false negatives and positives). Some errors outside of laboratory were included in this category for didactics effects, such as identification mislabeling, loss of specimen etc., because these errors may occur in or out of laboratory. official website and that any information you provide is encrypted and transmitted securely. In the multivariate analysis, the consultation with other pathologists, the diagnosis of malignancy, the use of immunohistochemistry, and the number of slides evaluated (11.3 when TAT>2days and 4.8 when TAT2days) remain as significantly associated with increased TAT. The most common errors found in this phase are: delay of the delivery of the results, failure to report or reporting to the wrong health care provider, transcription errors, incorrect results, misunderstanding of the results by the clinician, failure of clinician to see the report. J Surg Oncol. It is difficult sometimes to define an error because there exists a great variability in definitions used in the literature. Below, we will address the four most common laboratory errors: environmental, procedural, human, and instrumental. Read on to learn how to avoid making these common histology mistakes next time you are at the bench. Though its mandated that clinical labs require a system of quality control, its worth putting resources towards systems that can regularly address it, like a continuous quality improvement program. Either has the potential to cause patients harm. sharing sensitive information, make sure youre on a federal Standardization of Manual Method of Immunohistochemical Staining for Breast Cancer Biomarkers at Tertiary Cancer Care Center: An Audit. A total of 3147 amended reports from 1,667,547 surgical pathology specimens accessioned in the study. All Common Checklist, COM.06000, Specimen Collection Manual . This article considers how audit in histopathology can provide information about errors and inconsistencies in the diagnosis of surgical specimens. Some reasons may explain less attention to errors in medical labs when compared to other medical errors. Books > Its particularly necessary for histology labs that depend on their staff to prevent, catch, and handle errors. Even when clearly written, the numbers for slide identification can lead to confusion, such as when the lower horizontal bar of the number 2 on the middle slide is rather short and can be mistaken as number 7 [21]. The fifth difference was blinded and nonblinded reviews. Of the 199 permanent specimens, 99 (49.7%) were misinterpretations, and the most common subspecialty/anatomic location was gastrointestinal tract (including liver, pancreas, and biliary tract) with 23.2% (n=23), followed by breast (n=13, 13.1%), and lungs, pleura, and mediastinum (n=10, 10.1%). This is the most common classification of errors, based on the time and place of the laboratory where they occurred: in the pre-analytical, analytical, and post-analytical phases. Am J Gastroenterol. We describe a common, truly benign condition in the oral cavity, which due to histopathological misinterpretation was planned for major surgery and subsequent chemotherapy. 5 Princes Gate Court, Hanna MG, Pantanowitz L. Bar Coding and Tracking in Pathology. Misidentifications: contained four subtypespatient identification (lacking or wrong); tissue designation (e.g., lung confused with liver); laterality specification; and anatomic localization (e.g., skin of head misidentified as skin of hand). The study objective is to evaluate critical points in the process of pre-analytical histology in an Anatomic Pathology laboratory. Immediate scrutiny of urgent results with issue of provisional report and its delivery to the requesting clinician 3. Therefore, the most appropriate is to determine the accuracy, as a measure of diagnostic adequacy; it suggests that most of the qualified pathologists will agree on a similar diagnosis when analyzing the same specimen. Raab etal. Optimizing your LIMS to interface with all possible software and hardware is crucial to accurately track specimens as theyre processed, especially with workflow dashboards or status monitors that require frequent updating. Deficiencies in pre-laboratory steps can occur as well. In this work, 8346 histological cases were reviewed, for which 19,774 samples were made and from which 29,956 histologies were prepared. Registers and records were checked for efficiency and errors for pre-analytical quality variables: specimen identification, specimen in appropriate fixatives, lost specimens, daily internal quality control performance on staining, performance in inter-laboratory quality assessment program {External quality assurance program (EQAS)} and evaluatio. This proposed error taxonomy has shown a very good interobserver agreement of 91.4% (k=0.8780; 95% confidence limit, 0.84160.9144) when applied to amended reports. ABSTRACT The histopathological diagnosis. Errors in histopathology reporting: detection and avoidance . Besides that, the TTP is more complex and needs cooperation between several health institutions. Publishing on IntechOpen allows authors to earn citations and find new collaborators, meaning more people see your work not only from your own field of study, but from other related fields too. National Library of Medicine Some authors recommended that two pathologists sign-out every cancer diagnosis [40]; however, this entails greater manpower, a luxury not enjoyed by a few laboratory [29]. Most of the mistakes (69%, n=52) occurred in the gross examination room, 19 (25%) in the histology laboratory, and four (6%) were related to the pathologists errors. Histologic Preparations: Common Problems and Their Solutions-PUB123 - CAP lab error patient safety healthcare quality assessment It has been 12 years since the Institute of Medicine (IOM) reported the alarming data on the cause and impact of medical errors in the United States. We routinely observe the widespread use of inadequate containers, too small for the specimen, which make it difficult to withdraw. In container defects, the authors included missing specimen, container with no identified or misplaced label, absence or incorrect numeric patient identifier, absence of specimen type or source, and/or incorrect specimen type or source (or laterality). 2010 Sep;134(3):466-70. doi: 10.1309/AJCPHLQHJ0S3DFJK. In both situations, the consequences can be devastatingadverse effects or mutilations in treatment without clinical indications, with possibly fatal consequences, besides medical and legal consequences for the pathologist or laboratory involved in the biopsy process, with serious risks to the credibility and reputation of the pathologist and the laboratory. Even the errors of pathologists, when discovered, may modify their decision-making behaviors. [23], extraneous tissue found in stain bath, ranging in size from two to three cells to hundreds of cells, and the principal source of contamination was represented for the first sets of xylenes and alcohols. Heher YK, Chen Y, Pyatibrat S, Yoon E, Goldsmith JD, Sands KE. [31] performed a study to describe the frequency and types of error in surgical pathology reports. The main recommendations cited in the document, with strong agreement among the participants were: (1) pathologists should develop procedures for the evaluation of selected cases in order to detect divergences and possible interpretation errors, (2) pathologists should conduct case reviews timely to prevent negative impacts on patient care, (3) pathologists should have review procedures of cases relevant to their practice, as well as continuously monitor and document the results of case reviews, and (4) if case reviews show unsatisfactory concordances for a defined case type, the pathologists should take action to improve diagnostic compliance. HHS Vulnerability Disclosure, Help Identification errors involve misidentification of a patient or a specimen. In a study performed by Platt etal. document.getElementById( "ak_js_1" ).setAttribute( "value", ( new Date() ).getTime() ); The scientific writer and social media manager at GA International. It is broadly used in some expressions or phrases to communicate varying degrees of diagnostic certainty, for example, cannot rule out, consistent with, highly suspicious, favor, indefinite for, suggestive of, and worrisome for. Lindley, Gillies, and Hassell evaluated 1500 surgical pathology reports and found 35% of these expressions, with wide variation in the percentage of certainty clinicians assigned to the phrases studied. Dr. Alex Goldberg earned his Ph.D. in biology and previously worked as a post-doc in toxicology and medicine, studying chronological lifespan in yeast, anti-neoplastic small molecules, and the genetics of tuberous sclerosis complex. False-negative diagnosis of malignancy represented 52% of these claims, and 33% of these were false-positive diagnosis [30]. In a laboratory where prostate biopsies are exclusively evaluated, a little fragment of the prostate is less likely to be identified as extraneous. A LIMS can coordinate every step of the histological process, from sample processing to slide analysis, timestamping, and recording each sample as its passed from station to station. They identified 132 errors, such as accessioning (6.5%), gross dissecting (28%), processing (1.5%), embedding (4.5%), tissue cutting and slide mounting (23%), coloring, (1.5%), labeling, and releasing (35%). Measuring errors in surgical pathology in real-life practice: defining what does and does not matter. Morelli etal. A quality initiative to decrease pathology specimen-labeling errors using radiofrequency identification in a high-volume endoscopy center. In blinded revisions, the second pathologist had the same amount of information as the first one, and sometimes a blinded reviewer was given less case-specific information. Our team is growing all the time, so were always on the lookout for smart people who want to help us reshape the world of scientific publishing. Accessibility Nakhleh etal. Report defects: Defects of three subtypes were observed. Failure or aberrations in electronic formats or in the transmission of information in reports was considered the third subtype of error. The site is secure. Unauthorized use of these marks is strictly prohibited. Surprisingly, physicians and other interested people do not understand full aspects about the harmfulness of errors in laboratory medicine. Histology labs are frequently bombarded with patient samples that require mistake-free, timely processing to render the right diagnosis to the right patient. An extraneous tissue rate of 0.6% of slides (2074/321757) in the retrospective study and 2.9% of slides (1653/57083) was detected. Of this11 frozen section errors10 were misinterpretations and the most comprised malignant diagnosis in the central nervous system. 2008 Dec;130(6):905-12. doi: 10.1309/AJCPPIA5D7MYKDWF. According to the approach of the Institute of Medicine (IOM) to quality in healthcare, the identification of reliable quality indicators (QIs) is a crucial step in enabling users to quantify the quality of a selected aspect of care by comparing it against a defined criterion. Investing in continuing medical education, with emphasis on patient safety, as well as on the training of new pathologists, with a critical view aimed at reducing errors, is an obligatory path in improving the pathology practice. In the pre-analytic phase, they describe defective identification (patient, tissue, laterality, anatomic location) and defective specimen (loss of the specimen, erroneous in measurement or gross description, floaters, inadequate sampling, and the absence of indication of ancillary studies when necessary). 2007 Apr;141(4):450-5. doi: 10.1016/j.surg.2006.08.018. Amended reports in surgical pathology and implications for diagnostic error detection and avoidance: a College of American Pathologists Q-probes study of 1,667,547 accessioned cases in 359 laboratories. Another concern is that the patient does not understand the nature of the error or even that the clinician is unable to explain it adequately to the patient. Mr. Chapman has been presenting workshops and webinars for NSH, Region I and MaSH for over thirty years, and is the author/co-author of over . [ 3] Equally important is safety, which is defined as "freedom from accidental injury". Raab SS, Grzybicki DM, Mahood LK, Parwani AV, Kuan SF, Rao UN. Interpretation errors were responsible for 14.6% of the cases, 13.3% were identification errors, 13.7% were related to specimen errors, and 58.4% errors were of other modalities. Valenstein and Sirota [12] described four classifications of errors: Depending on the scenario in which error occurred, in pre-laboratory errors (identification errors external to reference laboratory) and laboratory errors. A study conducted at 14 laboratories in Australia examined a number of laboratory errors, including errors transcribing a patient's name from pathology requisitions to computer systems [Khoury M. Burnett L. . In many studies of total testing errors, analytical errors are often <10% and their frequency is decreasing due to standardization of laboratory procedures and assays, automation within the clinical pathology laboratory, and advances in technology (Plebani 2006, 2010; Sakyi et al. The specimen accession process is an intrinsic component of grossing and specimen quality assurance. official website and that any information you provide is encrypted While there are multiple types of errors including specimen identification, specimen processing and transcription errors, interpretive diagnostic errors tend to account for the majority of errors that affect the patient's course. In the preanalytic phase of testing, the pathologist must deal with clinical errors, specimen delivery errors, accessioning errors, errors due to incorrect specimen handling, and errors in the histology laboratory. Bixenstine etal. Before Pathology. Morphology is subjective and affected by the observers experience. In a study performed with 713 cases of surgical pathology, 551 (77%) were released in 2 days and 162 (23%) in 3 days or more. Identification errors can occur during any part of the test cycle; however, most occur in the preanalytic phase. Labels encounter many different harsh solvents throughout each step, the harshest being xylene. Out of the Maze? Delays in TAT may be considered during the pre-analysis as delays in reception, gross examination, and material processing; during the analysis (in the diagnostic interpretation of the pathologist) or after the analysis, as the delay in typing and release of the reports to the patient. In the cases of small biopsy, the risk of change in gross pathology is more dangerous. An integrated coordination between technical and managerial activities along with highly skilled pathologist is essential for the continuous, unimpeded realization of high quality, error-free, efficient and effective laboratory operations. Surgical pathology laboratory process is much more complex than highly mechanized processes with minimal human participation, such as clinical laboratory analysis. In the pre-analytical phase, the authors established a double-check system of the material, with the work divided into successive stages, and at each stage, all specimens were listed and checked by two team members, from receipt to material processing, and were subjected to the supervision of a quality control unit [16]. Evaluation of an automated preanalytical robotic workstation at two academic health centers. Besides that, the identification in the laboratory is critical as well. The focused review process detected approximately four times much more errors than the targeted 5% random review process, despite this last process involving the examination of almost 20 times the number of specimens. Errors in laboratory medicine and clinical pathology can occur at any point from specimen retrieval through specimen analysis; they are classified broadly as preanalytic phase, analytic phase, and postanalytic phase errors [9, 10]. Sometimes histology shows evidence of suspicious exogenous tissue sample, such as tumor cells with nuclear inclusions similar to arachnoidal cells in an endometrial sample, associated with the presence of eosinophilic amorphous material morphologically similar to secretory meningioma. Am. Clin Lab Med. In this chapter, we discuss the different concepts of error and diagnostic concordances in pathology, at which point in the diagnostic process the errors are more frequent, and propose solutions to minimize the chance of their occurrence. Requisition defects included the absence of requisition (or a blank requisition), date, time, name, specimen source/type, laterality, and/or numeric identifier (or when this information was wrong). Most of the identification errors occurred in skin, esophagus, kidneys, and colon biopsies, reflecting the distribution of types of cases received in surgical pathology, with small samples from endoscopy and dermatology. Methods: This study was conducted in a private histopatholgy referral center, named Delta Hospital Limited over a period of 3 days. FOIA . The impregnation and embedding of tissues are done by using the same medium usually but sometimes two different mediums are used for these processes (Double embedding). The site is secure. Categorizing Error Types in Histology - LabCE.com, Laboratory The .gov means its official. Fourth, in review performed by an expert, the exam was conducted by a specialist with extensive experience and knowledge in the field. If an error does occur, its better to assume that the system is at fault, rather than the staff. Excessive tissue trauma caused by tweezers and other surgical instruments (Figures 3 and 4), as well as the excessive use of electrocautery in the surgical margins, provoke artifacts that may lead to the need for a new biopsy collection. During the material reception, gross examination, and processing, there are many possibilities of error, from the exchange of samples or labels, absence or excessive cuts in the block, to cross-contamination with tissues foreign to the specimen included in the final slide. Because of that, the comparison of studies in literature can be difficult, as the authors used different definitions in their studies. [14] described critical points in pre-analytical steps in a pathology laboratory of a leading hospital in Lombardy, Italy. Troxel [26] reviewed records of lawsuits against pathologists for diagnostic negligence at a US insurance company responsible for the insurance of 1100 pathologists. Holman JW, Mifflin TE, Felder RA, Demers LM. 2006 May;130(5):620-5. doi: 10.5858/2006-130-620-SPRIRA. The development and testing of a laboratory information system-driven tool for pre-sign-out quality assurance of . Lower rates of deficiencies were identified in laboratories with lower numbers (<15,000) of accessioned cases and laboratories with a formal written plan for the detection of this type of errors [25]. Since the goals of pathology are multifaceted, it is easy to understand that there are multiple possibilities for error. 1,2 In response, companies have stepped up, designing automated machines for every step of the histological process. Hocking GR, Niteckis VN, Cairns BJ, Hayman JA. This article highlights seven common histology mistakes, all of which I have personally witnessed (supposedly intelligent and otherwise excellent) scientists commit. New York: Churchill Livingstone, 1994;4.2-1 - 4.2-39. The last difference was between focused reviews in which the examiner trained the diagnosis of specific types of cases and nonfocused revisions in which the pathologist evaluated a defined fraction of cases of various specimens or types of diagnoses. Disclaimer. In a study to develop a reproducible amendment taxonomy, Meier et al. Only 10% of the errors resulted in a delayed report to the physician. Correlation errors of freezing biopsy with conventional histology, University Hospital Getulio Vargas, Amazon, Brazil. The A3 method is based on defining a problem, analyzing its causes, aiming at an ideal practice, and providing an improvement plan [9]. As a staple of healthcareand life science research as wellerrors that occur during the histochemical process can have grave consequences. 20 Both quantitative and qualitative histology techniques exist; 20,21 however, both are time consuming, and biopsy collection is associated with tissue morbidity, pain, infection risk, long. Besides that, some expressions can lead to confusing interpretations. The .gov means its official. It has been suggested that up to 70% of all medical decisions are based on some kind of pathology and/or laboratory result.1 Medical testing consists of three phases: (a) pre-analytical, (b) analytical, and (c) post-analytical 2-4 Up to 75% of all medical testing errors occur during the pre-analytical phase with the majority happening before any.