Re: Risk management

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From:Tim Morken <>
Date:Wed, 08 Sep 1999 12:12:09 -0400 (EDT)
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My short answer is "zero percent." Of course, mistakes are made but they 
better be caught before a report goes out. Normally the mistakes are caught 
before cutting starts or when slides are matched with gross descriptions. I 
have seen  two mistakes of this sort reach the report stage but, knock on 
wood, never had one go to a clinician.

For risk managment I would say you need to have an oversight committee which 
looks into any major mistake, such as mixing up patient blocks (Any case of 
a mix up would qualify as a major mistake). As far as I am concerned a 
mistake caught in the lab before it goes to the pathologist doesn't count as 
a reportable mistake (that is, reportable to a lab QA committee. You would 
be wise to track it within your lab, however).

>From that point you need to track mistakes and, once data is gathered, 
decide whether you have a real problem and what to do about it.

Tim Morken, B.A., EMT(MSA), HTL(ASCP)
Infectious Disease Pathology
Centers for Disease Control
1600 Clifton Rd.
Atlanta, GA 30333


Phone: (404) 639-3964
FAX:  (404)639-3043

----Original Message Follows----
From: "Hall, Phil" <>
To: 'Histonet' <>
Subject: Risk management
Date: Wed, 08 Sep 1999 15:14:54 +0100

Does anyone have any idea of what percent of errors in slide  / block
labelling is acceptable in terms of clinical risk management?

Are there any papers or publications worth reading on risk management in

Phil Hall
St Michael's Hospital

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