Pub Date : 2006-12-01DOI: 10.1309/7GWUCGFLYG2VFHJ1
S. Raab, D. Grzybicki, J. Janosky, R. Zarbo, K. Geisinger, F. Meier, C. Jensen, Eva M. Wojcik, M. Haber, S. Geyer
Definition of Anatomic Pathology Testing Error Patient safety researchers and practitioners are not agreed on the definition of medical error.22,23 The IOM definition is that a medical error is the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim.3 Some have argued that this definition of error is too broad and classifies events as errors when in fact they may have occurred naturally in the course of normal medical care. For example, patient safety researchers disagree on the classification of a patient death immediately attributable to The Agency for Healthcare Research and Quality Hospital Labs Studying Patient Safety Consortium and Error Reduction Stephen S. Raab, MD,1 Dana M. Grzybicki, MD, PhD,1 Janine E. Janosky, PhD,2 Richard J. Zarbo, MD, DMD,3 Kim R. Geisinger, MD,4 Frederick A. Meier, MD,3 Chris Jensen, MD,5 Eva M. Wojcik, MD,6 Marian Haber, MD,7 and Stanley J. Geyer, MD8*
解剖病理检测错误的定义患者安全研究者和从业人员对医疗错误的定义不一致。22,23国际移民组织的定义是，医疗错误是指计划中的行动未能按计划完成或使用错误的计划来达到目的一些人认为，错误的定义过于宽泛，将事件归类为错误，而事实上，这些事件可能是在正常医疗过程中自然发生的。例如，患者安全研究人员对患者死亡的分类存在分歧，直接归结为医疗保健研究和质量医院实验室研究患者安全联盟和减少错误Stephen S. Raab, MD,1 Dana M. Grzybicki, MD, PhD,1 Janine E. Janosky, PhD,2 Richard J. Zarbo, MD, DMD,3 Kim R. Geisinger, MD,4 Frederick a . Meier, MD,3 Chris Jensen, MD,5 Eva M. Wojcik, MD,6 Marian Haber, MD,7和Stanley J. Geyer, MD8*
{"title":"The Agency for Healthcare Research and Quality Hospital Labs Studying Patient Safety Consortium and Error Reduction","authors":"S. Raab, D. Grzybicki, J. Janosky, R. Zarbo, K. Geisinger, F. Meier, C. Jensen, Eva M. Wojcik, M. Haber, S. Geyer","doi":"10.1309/7GWUCGFLYG2VFHJ1","DOIUrl":"https://doi.org/10.1309/7GWUCGFLYG2VFHJ1","url":null,"abstract":"Definition of Anatomic Pathology Testing Error Patient safety researchers and practitioners are not agreed on the definition of medical error.22,23 The IOM definition is that a medical error is the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim.3 Some have argued that this definition of error is too broad and classifies events as errors when in fact they may have occurred naturally in the course of normal medical care. For example, patient safety researchers disagree on the classification of a patient death immediately attributable to The Agency for Healthcare Research and Quality Hospital Labs Studying Patient Safety Consortium and Error Reduction Stephen S. Raab, MD,1 Dana M. Grzybicki, MD, PhD,1 Janine E. Janosky, PhD,2 Richard J. Zarbo, MD, DMD,3 Kim R. Geisinger, MD,4 Frederick A. Meier, MD,3 Chris Jensen, MD,5 Eva M. Wojcik, MD,6 Marian Haber, MD,7 and Stanley J. Geyer, MD8*","PeriodicalId":250671,"journal":{"name":"Pathology Patterns Reviews","volume":"21 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2006-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"125843777","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2006-12-01DOI: 10.1309/A68D7YJB2LMLBPJJ
D. Grzybicki, S. Raab
{"title":"Measuring Health Care Performance Identification and Standardization of Laboratory Quality Indicators","authors":"D. Grzybicki, S. Raab","doi":"10.1309/A68D7YJB2LMLBPJJ","DOIUrl":"https://doi.org/10.1309/A68D7YJB2LMLBPJJ","url":null,"abstract":"","PeriodicalId":250671,"journal":{"name":"Pathology Patterns Reviews","volume":"105 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2006-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"115853884","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2006-12-01DOI: 10.1309/9B7RWAYVVLCL58WW
E. Vamvakas
The debate about the existence of deleterious clinical effects of allogeneic blood transfusion (ABT)-related immunomodulation (TRIM) continues and is now concentrated on differing interpretations of findings of randomized controlled trials (RCTs). This review focuses on the results of studies reported during the last 5 years, especially recent RCTs, studies of the association of ABT with all-cause mortality, studies of the hypothesis attributing TRIM effects to WBC-derived soluble mediators that accumulate during storage, and studies comparing the risk of adverse outcomes before and after the implementation of WBC reduction of cellular blood components. When this literature is considered along with that available before 2001, the results from studies of adverse clinical TRIM effects remain contradictory. Based on the totality of the evidence, there seems to be an association between WBC-containing ABT and short-term (≤3 months posttransfusion) mortality that becomes manifest in cardiac surgery and in comparison with administration of allogeneic blood components filtered before storage. However, with the possible exception of cardiac surgery, there is no area in the extensive TRIM literature in which there is agreement among the studies or in which the observed clinical effects follow consistently from a postulated biologic mechanism. Allogeneic blood transfusion (ABT) results in the infusion into the recipient of large amounts of foreign antigens in soluble and cell-associated forms. The persistence of these antigens in the circulation of the recipient may create conditions that allow for the development of immune down-regulation. Evidence from a variety of sources indicates that ABT enhances the survival of renal allografts 1 and may increase the recurrence rate of resected malignant neoplasms 2 and the incidence of postoperative bacterial infections, 3-8 as well as reduce the recurrence rate of Crohn disease 9 and/or activate infections with cytomegalovirus or HIV. 10 This syndrome, the mechanisms and clinical relevance of which remain to be defined, has been referred to in the transfusion medicine literature as ABT-related immunomodulation (TRIM). 11,12
{"title":"Deleterious Clinical Effects of Allogeneic Blood Transfusion–Related Immunomodulation","authors":"E. Vamvakas","doi":"10.1309/9B7RWAYVVLCL58WW","DOIUrl":"https://doi.org/10.1309/9B7RWAYVVLCL58WW","url":null,"abstract":"The debate about the existence of deleterious clinical effects of allogeneic blood transfusion (ABT)-related immunomodulation (TRIM) continues and is now concentrated on differing interpretations of findings of randomized controlled trials (RCTs). This review focuses on the results of studies reported during the last 5 years, especially recent RCTs, studies of the association of ABT with all-cause mortality, studies of the hypothesis attributing TRIM effects to WBC-derived soluble mediators that accumulate during storage, and studies comparing the risk of adverse outcomes before and after the implementation of WBC reduction of cellular blood components. When this literature is considered along with that available before 2001, the results from studies of adverse clinical TRIM effects remain contradictory. Based on the totality of the evidence, there seems to be an association between WBC-containing ABT and short-term (≤3 months posttransfusion) mortality that becomes manifest in cardiac surgery and in comparison with administration of allogeneic blood components filtered before storage. However, with the possible exception of cardiac surgery, there is no area in the extensive TRIM literature in which there is agreement among the studies or in which the observed clinical effects follow consistently from a postulated biologic mechanism. Allogeneic blood transfusion (ABT) results in the infusion into the recipient of large amounts of foreign antigens in soluble and cell-associated forms. The persistence of these antigens in the circulation of the recipient may create conditions that allow for the development of immune down-regulation. Evidence from a variety of sources indicates that ABT enhances the survival of renal allografts 1 and may increase the recurrence rate of resected malignant neoplasms 2 and the incidence of postoperative bacterial infections, 3-8 as well as reduce the recurrence rate of Crohn disease 9 and/or activate infections with cytomegalovirus or HIV. 10 This syndrome, the mechanisms and clinical relevance of which remain to be defined, has been referred to in the transfusion medicine literature as ABT-related immunomodulation (TRIM). 11,12","PeriodicalId":250671,"journal":{"name":"Pathology Patterns Reviews","volume":"1 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2006-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"121059560","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2006-12-01DOI: 10.1309/MYJEA036EDQQEH4X
D. Novis, George Konstantakos
The use of quality benchmarking and performance tracking techniques has been successful in reducing errors in the practices of pathology and laboratory medicine. However, techniques developed in the manufacturing industry, specifically those pioneered by Toyota Motor have been more efficient and effective in reducing errors than those developed in the health care industry. We discuss some of those techniques and draw analogies as to how they might be applied in the laboratory. Traditional Approach to Error Reduction: Benchmarking and Best Practices For more than a decade and a half, the College of American Pathologists (CAP) has defined the nature of quality in the practices of laboratory medicine and anatomic pathology through its quality benchmarking Q-Probes program. By using these data collection tools, voluntary participants representing heterogeneous groups of hospitals and practice environments located in all geographic regions of the United States have measured standard parameters of quality. In each of these studies, enormous amounts of data were collected during periods lasting weeks to months. From these data, CAP statisticians have established benchmarks of laboratory performance. Participants have been able to gauge their performances relative to those of the national benchmarks determined in these studies and those of their peers participating in the studies. In each study, participants also have provided general information describing how laboratory services are provided in their institutions. CAP statisticians have used these data to determine which laboratory and professional practices are associated with superior outcomes.1-5 For example, 2 Q-Probes studies examined the frequencies of the following: (1) completion of 4 standard components of patient and blood unit identification before performing blood transfusions and (2) performance of required vital sign monitoring during the transfusions.6 Participants representing a total of 600 hospitals audited 16,494 transfusions. The median frequencies with which health care workers performed all patient identification and monitoring procedures ranged from 10.0% to 69.0% and 90.2% to 95.0%, respectively, in both studies. Individual practices and/or institutional policies associated with greater Reducing Errors in the Practices of Pathology and Laboratory Medicine An Industrial Approach David A. Novis, MD,1,2 and George Konstantakos3
使用质量基准和绩效跟踪技术已经成功地减少了病理和检验医学实践中的错误。然而，制造业开发的技术，特别是由丰田汽车公司开创的技术，在减少错误方面比医疗保健行业开发的技术更有效。我们将讨论其中的一些技术，并对它们如何在实验室中应用进行类比。十多年来，美国病理学家学院(CAP)通过其质量基准Q-Probes计划，定义了检验医学和解剖病理学实践中质量的本质。通过使用这些数据收集工具，代表美国所有地理区域的医院和实践环境的不同群体的自愿参与者测量了质量的标准参数。在每一项研究中，在数周到数月的时间里收集了大量的数据。根据这些数据，CAP统计人员建立了实验室绩效的基准。参与者能够根据这些研究确定的国家基准和参与研究的同龄人的基准来衡量他们的表现。在每项研究中，参与者还提供了描述其机构如何提供实验室服务的一般信息。CAP统计学家使用这些数据来确定哪些实验室和专业实践与更好的结果相关。例如，2项Q-Probes研究检查了以下频率:(1)在输血前完成患者和血液单位识别的4个标准组成部分，(2)在输血过程中执行必要的生命体征监测代表总共600家医院的参与者审计了16 494次输血。在两项研究中，卫生保健工作者执行所有患者识别和监测程序的中位数频率分别为10.0%至69.0%和90.2%至95.0%。个人实践和/或机构政策与更大程度地减少病理学和实验室医学实践中的错误有关:一种工业方法David A. Novis，医学博士1,2和George Konstantakos3
{"title":"Reducing Errors in the Practices of Pathology and Laboratory MedicineAn Industrial Approach","authors":"D. Novis, George Konstantakos","doi":"10.1309/MYJEA036EDQQEH4X","DOIUrl":"https://doi.org/10.1309/MYJEA036EDQQEH4X","url":null,"abstract":"The use of quality benchmarking and performance tracking techniques has been successful in reducing errors in the practices of pathology and laboratory medicine. However, techniques developed in the manufacturing industry, specifically those pioneered by Toyota Motor have been more efficient and effective in reducing errors than those developed in the health care industry. We discuss some of those techniques and draw analogies as to how they might be applied in the laboratory. Traditional Approach to Error Reduction: Benchmarking and Best Practices For more than a decade and a half, the College of American Pathologists (CAP) has defined the nature of quality in the practices of laboratory medicine and anatomic pathology through its quality benchmarking Q-Probes program. By using these data collection tools, voluntary participants representing heterogeneous groups of hospitals and practice environments located in all geographic regions of the United States have measured standard parameters of quality. In each of these studies, enormous amounts of data were collected during periods lasting weeks to months. From these data, CAP statisticians have established benchmarks of laboratory performance. Participants have been able to gauge their performances relative to those of the national benchmarks determined in these studies and those of their peers participating in the studies. In each study, participants also have provided general information describing how laboratory services are provided in their institutions. CAP statisticians have used these data to determine which laboratory and professional practices are associated with superior outcomes.1-5 For example, 2 Q-Probes studies examined the frequencies of the following: (1) completion of 4 standard components of patient and blood unit identification before performing blood transfusions and (2) performance of required vital sign monitoring during the transfusions.6 Participants representing a total of 600 hospitals audited 16,494 transfusions. The median frequencies with which health care workers performed all patient identification and monitoring procedures ranged from 10.0% to 69.0% and 90.2% to 95.0%, respectively, in both studies. Individual practices and/or institutional policies associated with greater Reducing Errors in the Practices of Pathology and Laboratory Medicine An Industrial Approach David A. Novis, MD,1,2 and George Konstantakos3","PeriodicalId":250671,"journal":{"name":"Pathology Patterns Reviews","volume":"72 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2006-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"129178372","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2006-12-01DOI: 10.1309/KVT7NWVPJR73T4K6
R. Zarbo, R. D'angelo
We describe the cultural transformation of the surgical pathology laboratory at Henry Ford Hospital, Detroit, MI, to one that has adopted an expectation for empowered workers to see their daily work in the context of continually learning and making effective process improvements that are designed and tested by the scientific method. This transformation has been achieved by creating an organizational and educational framework for implementing guiding principles originally systematized as the basis of lean manufacturing by our founder, Henry Ford, at the turn of the century, and incorporating the innovations of the Toyota Production System. We present novel data collection techniques to establish baseline states by which to gauge the success of changes and lessons from rapid process improvement studies. Herein, we share our experiences, lessons learned, and successes to date in the pathology-based Henry Ford Production System. We do not make changes for the sake of making them, but we never fail to make a change once it is demonstrated that the new way is better than the old way. We hold it our duty to permit nothing to stand in the way of progress. —Henry Ford 1
{"title":"Transforming to a Quality Culture","authors":"R. Zarbo, R. D'angelo","doi":"10.1309/KVT7NWVPJR73T4K6","DOIUrl":"https://doi.org/10.1309/KVT7NWVPJR73T4K6","url":null,"abstract":"We describe the cultural transformation of the surgical pathology laboratory at Henry Ford Hospital, Detroit, MI, to one that has adopted an expectation for empowered workers to see their daily work in the context of continually learning and making effective process improvements that are designed and tested by the scientific method. This transformation has been achieved by creating an organizational and educational framework for implementing guiding principles originally systematized as the basis of lean manufacturing by our founder, Henry Ford, at the turn of the century, and incorporating the innovations of the Toyota Production System. We present novel data collection techniques to establish baseline states by which to gauge the success of changes and lessons from rapid process improvement studies. Herein, we share our experiences, lessons learned, and successes to date in the pathology-based Henry Ford Production System. We do not make changes for the sake of making them, but we never fail to make a change once it is demonstrated that the new way is better than the old way. We hold it our duty to permit nothing to stand in the way of progress. —Henry Ford 1","PeriodicalId":250671,"journal":{"name":"Pathology Patterns Reviews","volume":"1199 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2006-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"116067433","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2006-12-01DOI: 10.1309/DML7PAKWH7LUL39C
M. Roberts
{"title":"The Use of Decision Analysis for Understanding the Impact of Diagnostic Testing Errors in Pathology","authors":"M. Roberts","doi":"10.1309/DML7PAKWH7LUL39C","DOIUrl":"https://doi.org/10.1309/DML7PAKWH7LUL39C","url":null,"abstract":"","PeriodicalId":250671,"journal":{"name":"Pathology Patterns Reviews","volume":"62 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2006-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"126272584","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2006-12-01DOI: 10.1309/54XR770U8WTEGG1H
M. Graber
{"title":"The physician and the laboratory: Partners in reducing diagnostic error related to laboratory testing:","authors":"M. Graber","doi":"10.1309/54XR770U8WTEGG1H","DOIUrl":"https://doi.org/10.1309/54XR770U8WTEGG1H","url":null,"abstract":"","PeriodicalId":250671,"journal":{"name":"Pathology Patterns Reviews","volume":"174 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2006-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"122816246","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2006-12-01DOI: 10.1309/6NU5LL8HU3C7LERL
D. Grzybicki, T. Merryman, D. Sharbaugh, S. Raab
{"title":"The Second Annual Improving Hospital and Laboratory Safety MeetingDiscussion Session Proceedings","authors":"D. Grzybicki, T. Merryman, D. Sharbaugh, S. Raab","doi":"10.1309/6NU5LL8HU3C7LERL","DOIUrl":"https://doi.org/10.1309/6NU5LL8HU3C7LERL","url":null,"abstract":"","PeriodicalId":250671,"journal":{"name":"Pathology Patterns Reviews","volume":"25 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2006-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"131284199","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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