[Histonet] Quality In AP

[Cristi Rigazio]

During a tumor board conference, a pancreatic cancer case was being reviewed.  The slide was shown and a pathologist pointed out the tissue was lung, not pancreas.  The patient was scheduled for surgery the following day.  It was promptly cancelled.  This incident started in the lab when the wrong section was placed on the slide, how it got all the way to a final report and subsequent surgery scheduling, I can't answer.  Is this the kind of example you are seeking?
Kind regards,
Cristi

Sent from my iPhone

On Mar 24, 2013, at 6:05 AM, Ian R Bernard <ibernard <@t> uab.edu> wrote:

> I'm in the process of writing a comprehensive Quality Management Program for our AP department.
> 
> I have references but would like some input from colleagues.
> 
> 
> -          Sentinel event involves death or serious physical or psychological injury.
> 
> -          Near Miss fall short of that.
> 
> Bottom-line, need some real life examples of near misses in Surgical pathology, Histopathology and Cytopathology.  Send me you input
> 
> IB
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