[Histonet] a question on ethics

Weems, Joyce JWEEMS <@t> sjha.org
Fri Aug 13 08:03:16 CDT 2004


Ron, I feel your pain!!

I'm not sure what your resources are. But if you have a risk manager, I would first of all ask your manager to meet with you and the risk manager. If she refused, I'd let her know that I intended to request a meeting. I would also involve the pathologists as they are at risk for malpractice.

The consensus of management gurus would be that processes cause most errors - not people. JCAHO now requires a "Root Cause Analysis" of serious error, to help determine what processes could be put into place to eliminate errors. I would review the error with this in mind to see what could be put into place to prevent errors and to catch them when they occur.

One suggestion would be to ink the tissue - not just different colored cassettes or slides. There are kits of dyes in neat little dispensers that you would rotate through all the skins that would be dictated in the gross to help identify the specimen. That way you would know that Patient A was red, B was blue, There would be very little one could do to separate two skins of like size, other than something like this, I would think. 

Didn't intend to write a book. Good luck! 
Joyce

Have a good weekend everyone!


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