Improving Patient Safety by Examining Pathology Errors

描述（由申请人提供）：提高患者安全的一个关键组成部分是减少医疗差错。关于解剖病理诊断错误及其对患者预后的影响的信息缺乏。许多先前发表的研究仅限于单一机构，报告的诊断错误率在所有接受活检或切除手术的患者中从不到1%到43%不等，错误和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、全国性的、自愿的解剖病理学错误数据库。这些数据将用于针对减少错误和改善临床结果的持续质量改进。将处理四个具体目标。首先，通过细胞学-组织学相关性和跨部门会议上对病例的二次回顾发现的档案和正在进行的错误及其相关结果，将在四个机构中进行回顾性识别并输入数据库。每个机构将把他们的错误数据输入到现场的网络数据库中，并将数据以电子方式发送给申请机构进行集中分析。其次，与这些错误和结果相关的季度和年度质量绩效报告将由申请机构的研究团队生成，并分发给每个机构。这些报告将包括总体诊断错误和结果百分比，特定机构错误和结果百分比，以及总体和特定机构

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.