2016 Annual Meeting

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

Room CC 604, March 16 2016, 8:00am to 12:00pm


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

Session Credits: 3 CME and 3 SAMs

Faculty: Carolyn Mies, MD, Hospital of University of Pennsylvania, Philadelphia, PA and Raouf Nakhleh, MD, Mayo Clinic-Florida, Jacksonville, FL

This course will help pathologists to understand how errors occur and how to reduce them in surgical pathology practice. General pathologists from all practice contexts academic, private and commercial -- will find it helpful. Senior trainees and early-career pathologists in the active phase of developing safe practice habits and 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 and 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, and unambiguous. The course will have narrative and case-based components, the latter comprising Breast Pathology case examples to illustrate points. Sources for addressing these QI issues include published studies and surveys on error-detection and reduction; studies of litigation involving surgical pathology; and published scholarly work on effective communication, focusing on concise writing to maximize comprehension. A course handout of the PowerPoint presentation will be available online prior to the meeting.

Upon completing this educational activity, participants should:

  1. Be conversant with the test-cycle framework for identifying, categorizing and correcting error
  2. Understand the general principles of error reduction and how to apply them in daily practice
  3. Grasp the scope of specimen identification/labeling mishaps (pre-analytic error) and 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
  6. Have learned a response sequence for managing erro rand controlling damage when it occurs.


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