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How Should We Identify Anatomic Pathology & Histology errors?

Following the attention drawn to patient safety due to medical errors by the Institute of Medicine's (IOM's) 1999 publication "To Err is Human," the Agency for Healthcare Research and Quality (AHRQ) funded four institutions to compile and perform further studies on patient safety in anatomic pathology testing.
The error identification method of secondary review which has traditionally been applied within anatomic pathology for error identification is especially problematic for prevention of patient harm according to the AHRQ. Secondary review methods include correlation studies, frozen section to permanent section diagnosis comparisons, and conference reviews. The secondary method, because it is retrospective in nature, does little to reduce patient risk, since it does not either correct or prevent testing cycle failures, but only helps identify them after the fact.
The AHRQ strongly recommends the adoption of methods such as root cause analysis over secondary review to create systems and processes which are better equipped to detect medical errors before they reach the end of the anatomic pathology test cycle. The root cause methodology proposed by the AHRQ is based on a modification of the Eindhoven Classifiction Model for the medical event reporting for transfusion medicine.
This RCA method identifies three domains:
  1. Technical - equipment, forms, and software
  2. Organizational - procedures, policies, and protocols
  3. Human - knowledge-based, rule-based, and skill-based

The AHRQ believes that the narrowing of focus into three specific domains has been very useful in identification of process problems in other healthcare systems that lead to patient risk, and they feel this methodology could also be effective in the classification of contributing factors and root causes of errors which lead to patient harm in anatomic pathology. In addition, the process based root cause framework highlights correctable process and system flaws versus a focus on human factors. This action-oriented approach has helped move organizations to a more proactive and nimble management within their medical error prevention strategy.