2017 Annual Meeting

The Insider’s Guide to Quality and Safety

Room CC Hemisfair 2, March 6 2017, 1:00pm to 5:00pm


The Insider’s Guide to Quality and Safety
Monday, March 6, 2017
1:00 PM 5:00 PM
CC Hemisfair 2

Session Credits: CME and SAMs

Course Director: Yael K. Heher MD, MPH, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA

Course Co-Director: Raouf Nakhleh MD, Mayo Clinic Florida, Jacksonville, FL

Course Description:
Pathologists have long been deeply invested in the quality of the care we provide. However, the increasing burden of clinical care, daily operations, and regulatory compliance have challenged the maintenance of a safe and high quality care environment. In parallel to increasing clinical demands, the health care community has become sharply focused on patient safety, with many major organizations calling on the laboratory to adapt to a culture of reliability, accountability, and transparency. Despite these shifts in the healthcare landscape, little to no specific tools exist to guide anatomic pathologists on exactly how to investigate medical errors and carry out quality improvement initiatives. This half day course will provide such a tool kit for frontline pathologists and pathologists-in-training. The course will be heavily case-based and interactive, utilizing a set of validated tools from the quality and safety literature and practical pathology-specific applications to facilitate learning.

Upon Completion of this educational activity, participants should be able to:

  • Understand the scope and breadth of quality and patient safety in anatomic pathology
  • Utilize published quality principles to reduce risk of diagnostic error in surgical pathology
  • Evaluate adverse events and near misses thoroughly and honestly using root cause analysis and the M&M model
  • Effectively analyze and target root causes that may have contributed to failure using validated process improvement tools
  • Optimize and standardize the pathology report as a communication tool to reduce errors and improve care
  • Understand the role of process mapping and workflow redesign in successful quality improvement initiatives
  • Describe the necessary elements of disclosure and the adverse event management process
  • Comfortably discuss and resolve common challenging scenarios in quality and patient safety for pathologists



1:00 PM

Introductory Lecture: What Is Quality and Safety in The Lab?

1:20 PM

Case 1: Diagnostic Error in Surgical Pathology: How Can We Reduce Risk?

1:40 PM

Case 2: M&M Rounds in Pathology: Root Cause Analysis, Transparency, and Process Improvement

2:00 PM


2:30 PM

Case 3: Communication in Pathology: A Model of Post-Analytic Quality

2:50 PM

Case 4: Histology Labeling Error: Process Mapping and Workflow Redesign

3:10 PM

Case 5: When Things Go Wrong: Disclosure and Adverse Event Management

3:30 PM


4:00 PM

Common Challenges in Quality & Safety: Role Play Session

4:40 PM

Questions and Discussion


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