Error reduction in surgical pathology.
BACKGROUND
Because of its complex nature, surgical pathology practice is inherently error prone. Currently, there is pressure to reduce errors in medicine, including pathology.


OBJECTIVE
To review factors that contribute to errors and to discuss error-reduction strategies.


METHODS
Literature review.


RESULTS
Multiple factors contribute to errors in medicine, including variable input, complexity, inconsistency, tight coupling, human intervention, time constraints, and a hierarchical culture. Strategies that may reduce errors include reducing reliance on memory, improving information access, error-proofing processes, decreasing reliance on vigilance, standardizing tasks and language, reducing the number of handoffs, simplifying processes, adjusting work schedules and environment, providing adequate training, and placing the correct people in the correct jobs.


CONCLUSIONS
Surgical pathology is a complex system with ample opportunity for error. Significant error reduction is unlikely to occur without a sustained comprehensive program of quality control and quality assurance. Incremental adoption of information technology and automation along with improved training in patient safety and quality management can help reduce errors.
Nakhleh
Raouf E
RE
Department of Pathology, St Luke's Hospital/Mayo Clinic Jacksonville, Jacksonville, FL 32216, USA. Nakhleh.Raouf@Mayo.edu