Based in Hanover, New Hampshire, Hypertherm is a company that manufactures arc welders. Ray works on the assembly line—he adds thermal sensors. But he can’t do so until he makes sure that his coworker Pete has installed the wiring correctly. Dupont’s Service Center in Dover, New Hampshire, approaches quality control (QC) in the same way. After Wayne replaces worn brake disks, his coworker Dave checks his work. It’s no different in my laboratory. Before we release patient results, our supervisor Janet looks over the worksheets.If it’s important enough for coworkers to check the wiring, the brakes, and the laboratory test results before the work goes out the door, is it less important for pathologists to check each other’s reports before those reports propel what may be irreversible therapy?
Pathologists seem to think not. In many institutions, they review surgical pathology cases for diagnoses they know to be error prone. These reviews are worth the effort. They uncover mistakes.1–4
But what about the less obvious cases, those that pathologists thought were so straightforward they did not need a second set of eyes—judgments that they may have later regretted?
HOW MUCH IS ENOUGH?
Ten percent of pathology practices review 17% of their caseloads before they release their reports to clinicians.2 Yet to date no one has connected the dots between that 17% and improved patient outcomes. Is 17% a real standard of quality or is it just an arbitrary number to which some pathology practices have gravitated?Some pathologists believe that reviewing all cases prior to release captures more errors.5–8 Unfortunately, how many of these errors harm patients is a number no one knows because no 2 pathologists who have studied errors have agreed on their definitions, their shelf lives, or even who has the authority to make those calls.4 Reaching a consensus on these questions may be moot—how serious we believe errors to be may be of little concern to patients whose pathology reports bear them.
Serious or not, when a report contains an error we know 2 things for sure: 1, the report contains an error; and 2, it has our name on it. So why don’t more pathology departments review every case before they release their reports?
Read full article at Archives of Pathology and Laboratory Medicine
