The College of American Pathologists (CAP) believes patient safety is threatened whenever health care quality is compromised. The CAP has taken a leadership role defining threats to patient safety that involve the practice of pathology and laboratory medicine, promoting practices that make health care safer and more reliable, and monitoring the effectiveness of patient safety initiatives.
Threats to Patient Safety
Threats to patient safety are manifold and resist any single classification. In the practice of pathology and laboratory medicine, patient safety can be imperiled by human error, patient or specimen misidentification, inaccurate order communication, improper specimen collection or handling, inappropriate use of laboratory services, failure to properly introduce new test systems, improper ongoing quality management of tests, reagent and instrument failure, ineffective reporting of test results, improper administration of blood products, failure to correct reporting errors, misinterpretation of test results, inadequate education or training, fraud, impaired employees, deficient information management practices, prolonged turnaround time, or an organizational culture that fails to emphasize the importance of quality, safety, motivation, responsiveness to customers, or quality standards.
Improving Patient Safety
Patient safety is promoted by processes, procedures, and innovations that may be applied at any number of levels, including the individual professional, manufacturer of reagents and instruments, the licensed clinical laboratory, a health care system, a professional society, or a governmental entity. The CAP promotes patient safety by requiring specific laboratory practices as part of the CAP Laboratory Accreditation Program, which accredits more than 6,000 U.S. laboratories, through professional education and ongoing professional training, support of an anonymous quality and safety reporting system, the development of Cancer Checklists and other reporting standards, support of research related to quality and patient safety, and advocacy for standards that further safety and high quality care.
Monitoring Patient Safety
The CAP believes patient safety and quality in pathology and laboratory medicine require ongoing monitoring by individuals, laboratories, professional societies, and governmental organizations. Monitoring should be designed to improve performance; punitive sanctions should be reserved for egregious quality failures, lest a “culture of safety” give way to a “culture of blame” that discourages reporting or the promotion of safety. The CAP monitors safety through creation of the first inter-laboratory Proficiency Testing program, which measures proficiency of testing at more than 20,000 U.S. laboratories, Q-Probes and Q-Tracks programs that enable laboratories to measure quality, safety, and customer satisfaction and compare performance with peers, SNOMED technology that establishes a standardized nomenclature for reporting medical errors, and recurring on-site inspection of every laboratory accredited by the CAP.
The College has also developed an initial core set of Laboratory Patient Safety Goals (LPSGs) for laboratories to use in their efforts to improve patient safety and reduce laboratory medical errors. The goals focus on the pre-analytic and post-analytic phases of laboratory testing with the objective of improving patient test management processes, including patient identification, test ordering, and critical results reporting and interpretation. The goals also reinforce the laboratory’s role in patient safety with the objective of improving identification, communication and correction of medical errors and integrate the laboratory’s patient safety role within health care organizations.
The College believes that any federally established center for patient safety should be a public-private partnership. Although the College supports a comprehensive, nationwide health systems approach to reducing and preventing medical errors, it has concerns about mandatory or voluntary reporting systems that have not been determined to improve patient safety and/or do not provide reporting safeguards with particular protection for confidentiality of information and individual protection from discovery of data in legal proceedings. The College supports passage of legislation to extend peer review protections to data related to patient safety.
Adopted May 2000
Revised August 2008