title: Detecting and preventing the occurrence of errors in the practices of laboratory medicine and anatomic pathology: 15 years' experience with the College of American Pathologists' Q-PROBES and Q-TRACKS programs.
abstract: This review extracts those studies from the CAP Q-PROBES and Q-TRACKS programs that have benchmarked and monitored the occurrence of errors in the practices of laboratory medicine and anatomic pathology. The outcomes of these studies represent in aggregate the analysis of millions of data points collected in thousands of hospitals throughout the United States. Also presented in this review are hospital and laboratory practices associated with improved performance (ie, fewer errors). Only those associations that were shown to be statistically significant are presented. They represent only a small fraction of the practices examined in these studies. The reader is encouraged to peruse the Q-PROBES studies cited in the reference list to learn about the wide range of practices investigated. The institution of some of these practices for which the associated error reductions were not statistically significant might nonetheless improve performance in some environments. There is no way of knowing whether some better-performing institutions compensated for not employing presumably beneficial practices by applying other practices about which the studies' authors neglected to inquire. Nor is there any way of knowing whether institutions in which performance was poor employed presumably beneficial practices, but possessed operational flaws about which the studies' authors neglected to inquire. Certainly, hospitals operating in the bottom 10% of benchmarked performances would do well to investigate the possibility that some of these practices might reduce the incidence of errors in their institutions. From the results of these studies, there emerge two complementary strategies that appear to be associated with reduction of errors. Obviously, the first strategy involves doing what is necessary to prevent the occurrence of errors in the first place. Several tactics may accomplish this goal. Healthcare workers responsible for specific tasks must be properly educated and motivated to perform those tasks with as few errors as possible. There must be written policies and protocols detailing responsibilities and providing contingencies when those responsibilities are not met. The successful completion of required tasks must be documented, especially those tasks that are performed as requisite to others. In other words, it should be impossible to move on to subsequent operations in testing processes before documenting the successful completion of previous requisite operations. Finally, the opportunities for making errors must be reduced. Specifically, the number of steps in which specimens are delivered to laboratories, tests are performed, and results are disseminated to those who use them must be reduced as much as possible. The second strategy involves the assumption that despite our best efforts to prevent them, errors will occur. No matter how smart we are, no matter how careful we try to be, we will make mistakes. It is essential that systems designed to eliminate errors include elements of redundancy to catch those mistakes. Work must be checked and verified before therapeutic decisions are finalized. This is especially true when those decisions are irrevocable and the potential damage caused by errors cannot be undone. Ideally, systems that use redundancy should include provisions to shut down the testing process altogether when the successful execution of previous steps cannot be verified. Once error detection systems are established, service providers can gauge their performance by employing tools of continuous monitoring to assess the degree to which health care workers comply with required procedures, and with which services achieve their intended outcomes.
authors.affiliation: Department of Pathology, Wentworth Douglass Hospital, Dover, NH 03820, USA. ynpa@rcn.com
authors.forename: David A
authors.initials: DA
authors.lastname: Novis
mesh_terms: D003951:Diagnostic Errors / Q000517:prevention & control*; D006801:Humans; D007591:Joint Commission on Accreditation of Healthcare Organizations; D007755:Laboratories, Hospital / Q000592:standards*; D010338:Pathology, Clinical / Q000592:standards*; D010340:Pathology, Surgical / Q000592:standards*; D012955:Societies, Medical; D014481:United States