Improving Patient Safety by Examining Pathology Errors

通过检查病理错误提高患者安全

• 批准号: 6772395
• 负责人: STEPHEN S RAAB
• 金额: $ 64.53万
• 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/6772395
• 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）：提高患者安全性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结局的影响的信息缺乏。许多先前发表的研究仅限于单一机构，并报告了所有接受活检或切除手术的患者的诊断错误百分比从不到1%到43%不等，错误与结果之间没有相关性。该项目的一个主要目标是建立一个基于网络的、病理学家驱动的、国家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，旨在减少错误和改善临床结局。将讨论四个具体目标。首先，通过细胞学-组织学相关性和部门间会议病例的二次审查检测到的存档和持续错误及其相关结局，将在四个机构进行回顾性识别并输入数据库。每家机构将其错误数据输入研究中心的网络数据库，并将日期以电子方式发送给申请机构进行集中分析。第二，申请机构的研究小组将编写与这些错误和结果有关的季度和年度质量绩效报告，并分发给每个机构。这些报告将包括总的诊断错误和结果百分比，机构特定的错误和结果百分比，以及总的和机构特定的 错误和结果百分比按多个潜在错误风险因素（如样本类型）分层。对这些数据的定量分析将产生客观的多机构业绩计量。具体因素（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，并根据根本原因分析的结果，在每个机构实施减少错误的计划。第四，这些干预措施的成功将通过监测干预后错误和错误对患者结局的影响来确定。该项目将提供有关诊断病理学错误的有价值的信息，它将为未来的研究奠定基础，重点是检查其他类型的诊断病理学错误和减少错误的程序在病理学实践中的影响。