Pathology Error / Stainer Bath Contamination

Giltnane, Jennifer M jennifer.giltnane at VANDERBILT.EDU
Wed Aug 14 02:56:24 UTC 2013


While I agree with Mark that framing bias is an important consideration, unfortunately we don't have direct access to the patient and the EMR is often bloated with "copy forward" H&Ps. Framing is especially dangerous when a specimen arrives with a diagnosis already rendered, as in your lymphoma example.  I'm not sure how best to improve this.
In my opinion, the clinical information should include enough data for the pathologist to be able to interpret and answer the question at hand, and of course this varies with every case and clinician. I recall Mike Lappsata saying that we (pathology in a general sense) receive the specimen chucked over a brick wall, and then chuck it back -- this has to change. More "facetime" interaction, facilitated by savvy design of our physical environment, is a core component of improvement. 
Regarding "floaters" - pieces of tissue from one case that end up in another case - most labs have protocols in place that minimize the impact of this error. For example, when samples are processed, we separate by sample type, and that carries down the line from embedding to cutting to staining. We are taught to seek out lesions on multiple levels, and even embedded floaters are usually both spatially separate from the true sample and also a different tissue type. I imagine that single organ type GU/GI/Derm labs that run at high-volume must have a different system, although I don't know the specifics. - Jena 

JM Giltnane, MD, PhD 









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