[Histonet] Quality In AP

Wed Mar 27 15:20:32 CDT 2013

Years ago (30+) while working as a clinical lab tech in the Navy, the histotech was thrown out of the histology department for doing sloppy histology work as fast as he could, I volunteered to work in histology.  After about 6 months of OJT and some training at AFIP I returned to the hospital and I assisted on an autopsy of a 30 y/o female that died of a malignant melanoma.  The new pathologist mentioned to me that she had had a skin biopsy done a 5-6 years earlier that was reported out as being negative for melanoma.  I dug the old slides and blocks out of the archives in the morgue and found the skin sample in the block was shriveled up in the paraffin.  The original slides showed no melanin and morphology was terrible.   

I back processed the tissue, re fixed it, reprocessed it, and cut new sections.  I restained the original slides and the new slides with H&E,  Fontana Masson, and Warthin Starry for melanin; the new slides showed melanoma was present in the skin biopsy,  the original slide quality was so bad (under fixed and poorly processed) that restaining barely showed melanin in the special stains.   I showed the newly stained slides to the pathologist and he informed me that I cost the navy about a half a million dollars in a lawsuit. 

After that the pathologist insisted that all tissue was fully fixed and he did not care how long he had to wait for his slides,  he wanted them all perfectly cut and stained perfectly.

James Watson HT  ASCP
GNF  Genomics Institute of the Novartis Research Foundation
Tel    858-332-4647
Fax   858-812-1915
jwatson <@t> gnf.org

-----Original Message-----
From: histonet-bounces <@t> lists.utsouthwestern.edu [mailto:histonet-bounces <@t> lists.utsouthwestern.edu] On Behalf Of Morken, Timothy
Sent: Wednesday, March 27, 2013 8:17 AM
To: Ian R Bernard
Cc: Histonet
Subject: RE: [Histonet] Quality In AP

Oh, several types of problems I can think of in 30+ years of work:

Labels switched on slides from two cases. Slides labeled correctly at microtome (hand written) but after staining the wrong paper label was put on the slide, and the label that should have been put on the slide was put on a different case. The correct slides and the wrong labels were both breast ca needle bx cases so the pathologist didn't catch that the mistake had happened. It only came to light when the other pathologist with the wrong label noticed the tissue section did not match those with IHC stains done on the same block. We traced back which slide must have gotten the wrong labels and notified the pathologist. He was just about to sign out the case.

Cytology cell blocks mixed up. Several cytology cell blocks prepared together. Eventually the mistake was caught, four months later, during a random QA review. Outcome was chemo for a patient that didn't need it (long term problem is  increased risk for cancer from the chemo), and no treatment for a patient that did need it (outcome, not treated as soon as could be). Tracing back we decided it was either mixed up at embedding or in cytology. Cytology was the probable source since blocks were (supposedly) always embedded individually at embedding. But we could not determine for sure where it happened.

Two  thyroid cases mixed up. At the microtome the cutter faced two thyroid blocks and put them back on ice. Slides were hand labeled for each block on the tray (against the rules - supposed to label slide only when block is being cut for sections). The cutter picked up a block, took sections and put them on the wrong slide. Same with second thyroid. The outcome was two patients getting the others treatment - one chemo, one surgery. 

I seems that no matter how many rules you put in place people always find a way to break them, intentionally (rushing, laziness is a type of intent) or not, it is all the same outcome - mistakes. 

We try to put in "engineered" controls - ways of doing things that cannot be short-cutted. That is hard to accomplish when any amount of "human nature" is involved. 

I tell my techs who fancy themselves as "fast" workers that NO ONE will remember how fast they were if they make major mistakes in the process. ONLY the mistakes will be remembered.

Tim Morken

-----Original Message-----
From: histonet-bounces <@t> lists.utsouthwestern.edu [mailto:histonet-bounces <@t> lists.utsouthwestern.edu] On Behalf Of Ian R Bernard
Sent: Wednesday, March 27, 2013 7:26 AM
To: Cristi Rigazio
Cc: histonet <@t> lists.utsouthwestern.edu
Subject: RE: [Histonet] Quality In AP

Yes. Any more examples of near misses in histology and cytology?  I will use these case studies and source of errors as examples.

Although this may have been obvious human error with the wrong section on the slide, a systems approach to quality improvement could have prevented this incident.

Building quality controls, assurances and improvement initiatives throughout the entire test cycle (pre analytical, analytical and post analytical) is key.

We also need to be aware of latent systems errors that may or may not be in our control but must be considered as we try to improve quality and reduce errors for patient safety.

IB

-----Original Message-----
From: Cristi Rigazio [mailto:cls71877 <@t> gmail.com] 
Sent: Sunday, March 24, 2013 9:58 AM
To: Ian R Bernard
Cc: histonet <@t> lists.utsouthwestern.edu
Subject: Re: [Histonet] Quality In AP

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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> Histonet <@t> lists.utsouthwestern.edu
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