New chapters on reducing and preventing errors in surgical pathology
and managing quality in histology and immunohistochemistry represent the
major updates in the CAP’s new book, Quality
Management in Anatomic Pathology: Promoting Patient Safety Through Systems
Improvement and Error Reduction, released this month.
"Quality of medical and laboratory services and patient safety issues
have really come to the fore in recent years," says Lawrence J. Burgart,
MD, of Mayo Clinic, Rochester, Minn., who chairs the CAP’s Surgical Pathology
Committee. "We’ve taken this opportunity to expand all of the areas that
deal with patient safety issues. In addition, immunohistochemistry has
become a much more prevalent part of laboratory practice, and material
has been added in that area. It’s a key resource for practicing pathologists."
The book is the latest version of the differently titled Quality
Improvement in Anatomic Pathology, released in 2001, and some of
the chapters are similar, says Patrick L. Fitzgibbons, MD, of St. Jude
Medical Center, Fullerton, Calif., who co-edited the volume with Raouf
Nakhleh, MD, of St. Luke’s Hospital/Mayo Clinic Jacksonville in Florida.
"We changed the name of the book to reflect a different emphasis," Dr.
Fitzgibbons says. "That’s one thing I was worried about: that people might
think it was a completely different book."
The revisions do significantly change the text’s approach to error reduction,
advocating a systems-based strategy that stays focused on the big picture,
says Dr. Nakhleh, who wrote the new chapter on error reduction in surgical
"The traditional view of errors and problems in the laboratory is to
blame individuals or look at problems in isolation, whereas if you’re
going to approach it from a quality assurance and quality improvement
perspective, you have to look at how things interact," he says. "You critically
look at how all the parts interact even though they appear to be removed
from one another." Make sure that fixes on one end do not introduce problems
on the other end, he says. "Maybe you’re trying to fix your car radio,
but that’s causing a short that shuts down the engine."
In addition to infusing that big-picture thinking into the manual, Dr.
Nakhleh says he and others who worked on Quality Management could
see unmet needs despite the "many positive comments" they had received
about the previous edition.
"People wanted more answers on how to reduce errors," he says. "And there
were areas not being addressed. For instance, we didn’t focus much [previously]
on the specifics of histology and immunohistochemistry. We needed to have
some solid footing from a quality assurance perspective in those areas."
The editors also tried to find opportunities to give time-pressed readers
the ability to reference specific problems quickly through checklists
and tables rather than have to wade through text, Dr. Nakhleh says.
"We have gone out of our way to try to make this user-friendly," he says,
citing as an example an updated chapter on regulatory information that
reflects the most recent CAP Laboratory Accreditation Program checklists.
"If you wanted to do something in quality assurance, you could very quickly
use this book and come up with a checklist or a table that you could incorporate
into your daily work.
"We hope they can use these as guidelines in doing quality assurance
in their own laboratories," he adds. "At another level, we’ve tried to
incorporate as many references into this book as possible, so that even
if we don’t have the specifics there ... the reference material may be
helpful in finding the answers."
The new chapter on preventing and reducing errors in surgical pathology
draws from successful strategies in other corners of the medical field
and from industry at large, Dr. Nakhleh says. "Certainly there are some
industries that are far more advanced in error reduction than medicine
in general and pathology," he says.
The chapter’s systems approach does not represent business-as-usual for
pathologists, says Dr. Fitzgibbons, who likens it to Six Sigma. "It’s
a more structured approach to how to design workflow," he says. "It’s
the direction we need to go, at least for anatomic pathology: How do we
identify where errors could occur? [Dr. Nakhleh] tried to present the
kinds of concepts you have to think about when you’re designing systems,
and what steps need to be done.
"It’ll be interesting for me to see how people react to it," he adds.
"It’s not something that pathologists are used to thinking about."