Improving Patient Safety by Examining Pathology Errors

通过检查病理错误提高患者安全

• 批准号: 6558834
• 负责人: STEPHEN S RAAB
• 金额: $ 66.01万
• 依托单位: UNIVERSITY OF PITTSBURGH AT PITTSBURGH
• 依托单位国家: 美国
• 财政年份: 2002
• 资助国家: 美国
• 起止时间: 2002-09-16 至 2007-08-31
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/6558834
• 关键词: Internet; biomedical registry /referral center; clinical research; cytology; data collection methodology /evaluation; diagnosis quality /standard; health care facility information system; health care personnel performance; health care service evaluation; health services research tag; human data; outcomes research; pathology; patient safety /medical error

DESCRIPTION (provided by applicant): A critical component of improving patient safety is reducing medical errors. A paucity of information exists on anatomic pathology diagnostic errors and their effect on patient outcomes. Many previously published studies are limited to single institutions and report variable diagnostic error percentages from less than 1 percent to 43 percent of all patients who undergo a biopsy or excisional procedure, with no correlation between error and outcome. A major goal of this project is to establish a Web-based, pathologist-driven, national, voluntary anatomic pathology error database. These data will be used for continuous quality improvement targeted at error reduction and clinical outcomes improvement. Four specific aims will be addressed. First, archival and on-going errors and their associated outcomes, detected by cytologic-histologic correlation and by secondary review of cases at interdepartmental conferences, will be identified retrospectively at four institutions and entered into the database. Each institution will enter their error data into the Web-based database on site, and the date will be sent electronically to the applicant institution for centralized analysis. Second, quarterly and annual quality performance reports, relating to these errors and outcomes, will be generated by the applicant institution research team and disseminated to each institution. These reports will include aggregate diagnostic error and outcome percentages, institution-specific error and outcome percentages, and aggregate and institution-specific error and outcome percentages stratified by multiple potential risk factors for error, such as specimen type. Quantitative analysis of these data will result in objective multi-institutional performance measures. Specific factors (e.g., specimen type, organ, clinical factors, pathologist and practice characteristics) associated with increased risk for diagnostic error will be identified. Third, root cause analysis will be performed to determine the potential sources of errors, and error reduction programs will be implemented at each institution, based on the results of the root cause analysis. Fourth, the success of these interventions will be determined by monitoring post-interventional error and the effects of error on patient outcomes. This project will provide valuable information regarding diagnostic pathology errors; it will set the groundwork for future studies focused on the examination of other types of diagnostic pathology error and the effect of error reduction programs in pathology practice.

描述(由申请人提供)：改善患者安全的一个关键组成部分是减少医疗差错。关于解剖病理学诊断错误及其对患者预后的影响的信息很少。之前发表的许多研究仅限于单一机构，报告的诊断错误百分比在接受活组织检查或切除手术的所有患者中从不到1%到43%不等，错误与结果之间没有相关性。这个项目的一个主要目标是建立一个基于Web的、病理学家驱动的、全国性的、自愿的解剖病理学错误数据库。这些数据将用于持续质量改进，目标是减少差错和改善临床结果。将解决四个具体目标。首先，通过细胞学-组织学相关性和在部门间会议上对病例的二次审查发现的档案和持续的错误及其相关结果，将在四个机构进行回顾确定并输入数据库。每个机构将其错误数据输入现场的基于Web的数据库，并将数据以电子方式发送给申请机构进行集中分析。第二，与这些错误和结果有关的季度和年度质量绩效报告将由申请机构研究小组编制并分发给每一所机构。这些报告将包括综合诊断错误和结果百分比、特定于机构的错误和结果百分比、以及综合和特定机构 按多种潜在的错误风险因素(如样本类型)分层的错误和结果百分比。对这些数据的量化分析将产生客观的多机构业绩衡量标准。将确定与诊断错误风险增加相关的特定因素(例如，标本类型、器官、临床因素、病理学家和实践特征)。第三，将进行根本原因分析，以确定潜在的错误来源，并将根据根本原因分析的结果，在每个机构实施减少错误的方案。第四，这些干预的成功将通过监测介入后错误和错误对患者预后的影响来决定。这个项目将提供有关诊断病理学错误的有价值的信息；它将为未来专注于检查其他类型的诊断病理学错误以及减少错误的计划在病理学实践中的效果的研究奠定基础。