Re: Risk management

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From:Tim Morken <timcdc@hotmail.com>
To:HistoNet@pathology.swmed.edu
Reply-To:
Date:Wed, 08 Sep 1999 12:12:09 -0400 (EDT)
Content-Type:text/plain; format=flowed

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
MS-G32
1600 Clifton Rd.
Atlanta, GA 30333
USA

email: tim9@cdc.gov
       timcdc@hotmail.com

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


----Original Message Follows----
From: "Hall, Phil" <Phil.Hall@ubht.swest.nhs.uk>
To: 'Histonet' <HistoNet@pathology.swmed.edu>
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
Histopathology?

Phil Hall
Pathology
St Michael's Hospital
BRISTOL
UK






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