2015 Annual Meeting

SC22-Practical Guide to Error Reduction, Effective Communication and Damage Control in Surgical Path

2015 Annual Meeting

Room CC 206, March 26 2015, 1:00pm to 4:30pm

Carolyn Mies, Raouf E. Nakhleh

Educational Objective

This course will help pathologists to understand how errors occur & how to reduce them in surgical pathology practice. General pathologists from all practice contexts – academic, private and commercial -- will find it helpful. Senior trainees & early-career pathologists in the active phase of developing safe practice habits & an effective communication style will benefit most. This Quality Improvement (QI) course addresses aspects of each of the 3 test-cycle phases, but focuses most on the pre-analytic and post-analytic components. It complements the many other Short Courses dealing with the analytic (interpretive) tasks of surgical pathology practice. Both systems-based (“systemic”) error & causes of error the individual pathologist can mitigate in daily practice are discussed. Among the latter, the course will highlight best practices for writing pathologic diagnoses that are not only accurate, but are on-point clinically, concise, & unambiguous. The course will have narrative & case-based components, the latter comprising Breast Pathology case examples to illustrate points. Sources for addressing these QI issues include published studies & surveys on error-detection & reduction; studies of litigation involving surgical pathology; & published scholarly work on effective communication, focusing on concise writing to maximize comprehension. Prior to the meeting, course registrants will receive a handout of the PowerPoint presentation and can access it via the web after the meeting. Upon completing this educational activity, participants should be able to:

  1. be conversant with the test-cycle framework for identifying, categorizing & correcting error;
  2. understand the general principles of error reduction & how to apply them in daily practice;
  3. grasp the scope of specimen identification/labeling mishaps (pre-analytic error) & how to implement an elimination/reduction strategy;
  4. appreciate the medico-legal implications of post-analytic error;
  5. know some language-based strategies for writing a concise, easily understood final report; and
  6. have learned a response sequence for managing error & controlling damage when it occurs.

Session Credits: CME = 3 / SAMs = N/A


SC Speaker
Speaker: Carolyn Mies, MD, Hospital of University of Pennsylvania, Philadelphia, PA
Access to Handouts
SC Speaker
Speaker: Raouf Nakhleh, MD, Mayo Clinic-Florida, Jacksonville, FL
Access to Handouts


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