Pathology Error / Stainer Bath Contamination
Bayardo.Perez-Ordonez at UHN.CA
Wed Aug 14 13:02:34 UTC 2013
In my experience "framing" is not the major problem in diagnostic pathology. We a have set of data (microscopic findings) to compare against diagnostic possibilities (differential diagnosis) before rendering a "final diagnosis". Any discrepancies between these two sets of data have to be resolved before a final report is issued. In many cases, (for example "mass base of tongue") may represent squamous cell carcinoma, lymphoma, lymphoid hyperplasia, and a long list of possible but less likely diagnoses. Do the microscopic findings fit any of the most common diagnoses? In a typical squamous cell carcinoma, reaching a diagnosis is a very quick process but in other cases, the microscopic findings do not support the presumed diagnosis therefore, we have to expand our differential and perhaps use appropriate ancillary studies (another decision making fork) like immunohistochemistry and molecular tests. Another limitation is sample size which raises the question of "Can I render this diagnosis with any degree of confidence and reproducibility in a sample of this size and subject a patient to radical therapy"?
The situation in non-tumor pathology is somewhat different because microscopic findings may fit a range of diagnostic possibilities. Drug injury, autoimmune disorders, infection, etc. Clinical information in this context is even more important for a helpful pathology report.
Our main problem is the lack of clinical/radiologic information in which to interpret microscopic findings. In the setting of subspecialty pathology, this is becoming less and less of a problem because pathologists are integrated in the clinical management team, but this type of setting is largely seen only in large academic centers.
Bayardo Perez-Ordonez, MD, FRCPC
Director of Surgical Pathology
Department of Pathology
University Health Network
200 Elizabeth Street
Toronto, Ontario M5G 2C4
bayardo.perez-ordonez at uhn.ca
From: Giltnane, Jennifer M [mailto:jennifer.giltnane at VANDERBILT.EDU]
Sent: Tuesday, August 13, 2013 10:56 PM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Subject: Re: [IMPROVEDX] Pathology Error / Stainer Bath Contamination
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
Moderator: Lorri Zipperer Lorri at ZPM1.com, Communication co-chair, Society for Improving Diagnosis in Medicine
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