title: Quality and patient safety in the diagnosis of breast cancer.
abstract: The media, medical legal, and safety science perspectives of a laboratory medical error differ and assign variable levels of responsibility on individuals and systems. We examine how the media identifies, communicates, and interprets information related to anatomic pathology breast diagnostic errors compared to groups using a safety science Lean-based quality improvement perspective. The media approach focuses on the outcome of error from the patient perspective and some errors have catastrophic consequences. The medical safety science perspective does not ignore the importance of patient outcome, but focuses on causes including the active events and latent factors that contribute to the error. Lean improvement methods deconstruct work into individual steps consisting of tasks, communications, and flow in order to understand the affect of system design on current state levels of quality. In the Lean model, system redesign to reduce errors depends on front-line staff knowledge and engagement to change the components of active work to develop best practices. In addition, Lean improvement methods require organizational and environmental alignment with the front-line change in order to improve the latent conditions affecting components such as regulation, education, and safety culture. Although we examine instances of laboratory error for a specific test in surgical pathology, the same model of change applies to all areas of the laboratory.
authors: Department of Laboratory Medicine, Eastern Health and Memorial University of Newfoundland, St. John's, Newfoundland and Labrador, Canada. stephen.raab@easternhealth.ca
authors: Stephen S
authors: SS
authors: Raab
authors: Justin
authors: J
authors: Swain
authors: Natasha
authors: N
authors: Smith
authors: Dana M
authors: DM
authors: Grzybicki
mesh_terms: D001943:Breast Neoplasms / Q000175:diagnosis*; D003951:Diagnostic Errors; D005260:Female; D006801:Humans; D007753:Laboratories / Q000592:standards; D061214:Patient Safety; D011785:Quality Assurance, Health Care
keywords: Breast pathology; Lean; Medical error; Patient safety; Quality improvement