title: Analysis of errors in histology by root cause analysis: a pilot study.
abstract: BACKGROUND
  The study objective is to evaluate critical points in the process of pre-analytical histology in an Anatomic Pathology laboratory. Errors are an integral part of human systems, including the complex system of Anatomic Pathology. Previous studies focused on errors committed in diagnosis and did not consider the issues related to the histology preparation of routine processes.
  
  
  METHODS
  Root Cause Analysis was applied to the process of histology preparation in order to identify the root cause of each previously identified problem. The analysis started by defining an 'a priori' list of errors that could occur in the histology preparation processes. During a three-month period, a trained technician tracked the errors encountered during the process and reported them on a form. 'Fishbone' diagram and 'Five whys' methods were then applied
  
  
  RESULTS
  8,346 histological cases were reviewed, for which 19,774 samples were made and from which 29,956 histologies were prepared. 132 errors were identified. Errors were detected in each phase: accessioning (6.5%), gross dissecting (28%), processing (1.5%), embedding (4.5%), tissue cutting and slide mounting (23%), coloring, (1.5%), labeling and releasing (35%).
  
  
  CONCLUSIONS
  Root cause analysis is effective and easy to use in clinical risk management. It is an important step for the identification and prevention of errors, that are frequently due to multiple causes. Developing operators' awareness of their central role in the risk management process is possible by targeted training. Furthermore, by highlighting the most relevant points of interest, it is possible to improve both the methodology and the procedural safety.
authors.affiliation: Hospital of Novi Ligure, Italy. pamemorelli@hotmail.com
authors.forename: P
authors.initials: P
authors.lastname: Morelli
authors.affiliation: Centre for Research on Health Economics, Social and Health Care Management (CREMS), Carlo Cattaneo University, LIUC, Castellanza, Italy.
authors.forename: E
authors.initials: E
authors.lastname: Porazzi
authors.affiliation: Hospital Authority Fatebenefratelli e Oftalmico, Milan, Italy.
authors.forename: M
authors.initials: M
authors.lastname: Ruspini
authors.affiliation: Centre for Research on Health Economics, Social and Health Care Management (CREMS), Carlo Cattaneo University, LIUC, Castellanza, Italy.
authors.forename: U
authors.initials: U
authors.lastname: Restelli
authors.affiliation: IRCCS Istituto Ortopedico Galeazzi, Milan, University of Milan, Italy.
authors.forename: G
authors.initials: G
authors.lastname: Banfi
mesh_terms: D003951:Diagnostic Errors; D005260:Female; D006652:Histological Techniques; D006801:Humans; D008297:Male; D010865:Pilot Projects; D012308:Risk Management; D060891:Root Cause Analysis