Anatomic Pathology Databases and Patient Safety

35 years after CLIA 1988: Key insights and policy implications among laboratory professionals

The Clinical Laboratory Improvement Amendments (CLIA) regulations of 1988 required certification of some clinical laboratory professionals but not of others. Analyzing survey data 35 years later, we explore how laboratory professionals today are inadvertently affected by those regulations, specifically their sense of professional identity and their perceptions of justice-and the consequences of those on their turnover intentions. Turnover is a major concern among laboratory professionals. Survey results show that even 35 years after the unintended disenfranchisement caused by CLIA, clinical laboratory professionals whose specialty was included in CLIA have a stronger sense of being an ingroup, expressed as positive professional identity, and had a higher assessment of there being procedural and distributive justice than those excluded in CLIA. Turnover intentions, however, were primarily a matter of negative professional identity and reduced distributive justice.

Multicenter Assessment of Gram Stain Error Rates

Gram stains remain the cornerstone of diagnostic testing in the microbiology laboratory for the guidance of empirical treatment prior to availability of culture results. Incorrectly interpreted Gram stains may adversely impact patient care, and yet there are no comprehensive studies that have evaluated the reliability of the technique and there are no established standards for performance. In this study, clinical microbiology laboratories at four major tertiary medical care centers evaluated Gram stain error rates across all nonblood specimen types by using standardized criteria. The study focused on several factors that primarily contribute to errors in the process, including poor specimen quality, smear preparation, and interpretation of the smears. The number of specimens during the evaluation period ranged from 976 to 1,864 specimens per site, and there were a total of 6,115 specimens. Gram stain results were discrepant from culture for 5% of all specimens. Fifty-eight percent of discrepant results were specimens with no organisms reported on Gram stain but significant growth on culture, while 42% of discrepant results had reported organisms on Gram stain that were not recovered in culture. Upon review of available slides, 24% (63/263) of discrepant results were due to reader error, which varied significantly based on site (9% to 45%). The Gram stain error rate also varied between sites, ranging from 0.4% to 2.7%. The data demonstrate a significant variability between laboratories in Gram stain performance and affirm the need for ongoing quality assessment by laboratories. Standardized monitoring of Gram stains is an essential quality control tool for laboratories and is necessary for the establishment of a quality benchmark across laboratories.

The Global Tracheostomy Collaborative: one institution's experience with a new quality improvement initiative

OBJECTIVE

Given the low frequency of adverse events after tracheostomy, individual institutions struggle to collect outcome data to generate effective quality improvement protocols. The Global Tracheostomy Collaborative (GTC) is a multi-institutional, multi-disciplinary organization that utilizes a prospective database to collect data on patients undergoing tracheostomy. We describe our institution's preliminary experience with this collaborative. It was hypothesized that entry into the database would be non-burdensome and could be easily and accurately initiated by skilled specialists at the time of tracheostomy placement and completed at time of patient discharge.

METHODS

Demographic, diagnostic, and outcome data on children undergoing tracheostomy at our institution from January 2013 to June 2015 were entered into the GTC database, a database collected and managed by REDCap (Research Electronic Data Capture). All data entry was performed by pediatric otolaryngology fellows and all post-operative updates were completed by a skilled tracheostomy nurse. Tracked outcomes included accidental decannulation, failed decannulation, tracheostomy tube obstruction, bleeding/tracheoinnominate fistula, and tracheocutaneous fistula.

RESULTS

Data from 79 patients undergoing tracheostomy at our institution were recorded. Database entry was straightforward and entry of patient demographic information, medical comorbidities, surgical indications, and date of tracheostomy placement was completed in less than 5min per patient. The most common indication for surgery was facilitation of ventilation in 65 patients (82.3%). Average time from admission to tracheostomy was 62.6 days (range 0-246). Stomal breakdown was seen in 1 patient. A total of 72 patients were tracked to hospital discharge with 53 patients surviving (88.3%). No mortalities were tracheostomy-related.

CONCLUSION

The Global Tracheostomy Collaborative is a multi-institutional, multi-disciplinary collaborative that collects data on patients undergoing tracheostomy. Our experience proves proof of concept of entering demographics and outcome data into the GTC database in a manner that was both accurate and not burdensome to those participating in data entry. In our tertiary care, pediatric academic medical center, tracheostomy continues to be a safe procedure with no major tracheostomy-related morbidities occurring in this patient population involvement with the GTC has shown opportunities for improvement in communication and coordination with other tracheostomy-related disciplines.

Metabolic imaging in multiple time scales

We report here a novel combination of time-resolved imaging methods for probing mitochondrial metabolism in multiple time scales at the level of single cells. By exploiting a mitochondrial membrane potential reporter fluorescence we demonstrate the single cell metabolic dynamics in time scales ranging from microseconds to seconds to minutes in response to glucose metabolism and mitochondrial perturbations in real time. Our results show that in comparison with normal human mammary epithelial cells, the breast cancer cells display significant alterations in metabolic responses at all measured time scales by single cell kinetics, fluorescence recovery after photobleaching and by scaling analysis of time-series data obtained from mitochondrial fluorescence fluctuations. Furthermore scaling analysis of time-series data in living cells with distinct mitochondrial dysfunction also revealed significant metabolic differences thereby suggesting the broader applicability (e.g. in mitochondrial myopathies and other metabolic disorders) of the proposed strategies beyond the scope of cancer metabolism. We discuss the scope of these findings in the context of developing portable, real-time metabolic measurement systems that can find applications in preclinical and clinical diagnostics.

College of American Pathologists Considerations for the Delineation of Pathology Clinical Privileges

Context.—The Joint Commission (JC) established new medical staff privileging requirements effective January 2008. The new requirements include the development of ongoing professional practice evaluation (OPPE) and focused professional practice evaluation (FPPE) processes and incorporate the general competencies of patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism and systems-based practice jointly developed by the Accreditation Council for Graduate Medical Education (ACGME) and the American Board of Medical Specialties (ABMS). The College of American Pathologists makes resources available to assist members and their facilities in implementing the new requirements and improving patient care.

Objectives.—To review the general requirements for privileging and identify how they may apply to pathologists, to identify currently available activities and metrics that may be useful in addressing these requirements, and to present identified concepts, activities, and metrics for consideration by pathologists and hospitals for their adaptation into the policies and procedures that address the new JC physician privileging requirements.

Design.—Review available pathology privileging documentation that addressed the previous JC requirements, review the new requirements, and search for and review available and applicable resources, activities, and metrics.

Results.—Common pathology activities and metrics can be incorporated into the privileging processes. Current and new activities and metrics can be incorporated or developed to address the 6 ACGME/ABMS “General Competencies.”

Conclusion.—Each hospital has unique privileging and physician evaluation requirements. Providing concepts, activities, and metrics for pathologists and hospitals to consider in pathology privileging will help implement the OPPE and FPPE processes and meet medical staff privileging requirements.

Laboratory medicine quality indicators: a review of the literature

We summarize information on quality indicators related to laboratory testing from published literature and Internet sources to assess current gaps with respect to stages of the laboratory testing process, the Institute of Medicine (IOM) health care domains, and quality measure evaluation criteria. Our search strategy used various general and specific terms for clinical conditions and laboratory procedures. References related to a potential quality indicator associated with laboratory testing and an IOM health care domain were included. With the exception of disease- and condition-related indicators originating from clinical guidelines, the laboratory medicine quality indicators reviewed did not satisfy minimum standard evaluation criteria for quality or performance measures (ie, importance, scientific acceptability, and feasibility) and demonstrated a need across the total laboratory testing process for consistently specified, useful, and evidence-based, laboratory-related quality and performance measures that are important to health outcomes and meaningful to health care stakeholders for which laboratories can be held accountable.

Opportunities to improve quality in laboratory medicine

Modern laboratories offer cost-effective and precise analysis of specimens. Unfortunately, accurate laboratory tests still can result in bad outcomes because of errors in the pre- and postanalytic phases of testing. Important sources of error in the preanalytic phase include errors in test ordering, patient identification, specimen collection, transport, and accessioning. Errors in the postanalytic phase often relate to turn-around time, delivery of reports, or interpretation of results. This article focuses on the key opportunities for improvement in quality.

Medical laboratory informatics

Laboratory informatics is the application of computers and information systems to information management in the pathology laboratory. Effective information management is crucial to the success of pathologists and laboratorians. Informatics has become one of the key pillars of pathology, and the requirement for skilled informaticists in the laboratory has quickly grown. This article provides a wide-ranging review of pertinent aspects of laboratory informatics, and deals with important technical and management processes. Topics covered include personal computing, networks, databases, fundamentals and advanced functions of the laboratory information system, interfaces and standards, digital imaging, coding, hospital information systems and electronic medical records.

Original research in pathology: judgment, or evidence-based medicine?

Pathology is both a medical specialty and an investigative scientific discipline, concerned with understanding the essential nature of human disease. Ultimately, pathology is accountable as well, as measured by the accuracy of our diagnoses and the resultant patient care outcomes. As such, we must consider the evidence base underlying our practices. Within the realm of Laboratory Medicine, extensive attention has been given to testing accuracy and precision. Critical examination of the evidence base supporting the clinical use of specific laboratory tests or technologies is a separate endeavor, to which specific attention must be given. In the case of anatomic pathology and more specifically surgical pathology, the expertise required to render a diagnosis is derived foremost from experience, both personal and literature-based. In the first instance, knowledge of the linkage between one's own diagnoses and individual patient outcomes is required, to validate the role of one's own interpretations in the clinical course of patients. Experience comes from seeing this linkage first hand, from which hopefully comes wisdom and, ultimately, good clinical judgment. In the second instance, reading the literature and learning from experts is required. Only a minority of the relevant literature is published in pathology journals to which one may subscribe. A substantial portion of major papers relevant to the practice of anatomic pathology are published in collateral clinical specialty journals devoted to specific disease areas or organs. Active effort is therefore required to seek out the literature beyond the domain of pathology journals. In examining the published literature, the essential question then becomes: Does the practice of anatomic pathology fulfill the tenets of 'evidence-based medicine' (EBM)? If the pinnacle of EBM is 'systematic review of randomized clinical trials, with or without meta-analysis', then anatomic pathology falls far short. Our published literature is largely observational in nature, with reports of case series (with or without statistical analysis) constituting the majority of our 'evidence base'. Moreover, anatomic pathology is subject to 'interobserver variation', and potentially to 'error'. Taken further, individual interpretation of tissue samples is not an objective endeavor, and it is not easy to fulfill the role of a 'gold standard'. Both for rendering of an overall interpretation, and for providing the semi-quantitative and quantitative numerical 'scores' which support evidence-based clinical treatment algorithms, the Pathologist has to exercise a high level of interpretive judgment. Nevertheless, the contribution of anatomic pathology to 'EBM' is remarkably strong. To the extent that our judgmental interpretations become data, our tissue interpretations become the arbiters of patient care management decisions. In a more global sense, we support highly successful cancer screening programs, and play critical roles in the multidisciplinary management of complex patients. The true error is for the clinical practitioners of 'EBM' to forget the contribution to the supporting evidence base of the physicians that are Anatomic Pathologists. Finally, the academic productivity of pathology faculty who operate in the clinical realm must be considered. A survey of six North American academic pathology departments reveals that 26% of all papers published in 2005 came from 'unfunded' clinical faculty. While it is likely that their academic productivity is lower than that of 'funded' research faculty, the contribution of clinical faculty to the knowledge base for the practice of modern medicine, and to the academic reputation of the department, must not be overlooked. The ability of clinical faculty in academic departments of pathology to pursue original scholarship must be supported if our specialty is to retain its preeminence as an investigative scientific discipline in the age of EBM.

Surgical specimen identification errors: a new measure of quality in surgical care

BACKGROUND

Communication errors are the primary factor contributing to all types of sentinel events including those involving surgical patients. One type of communication error is mislabeled specimens. The extent to which these errors occur is poorly quantified. We designed a study to measure the incidence and type of specimen identification errors in the surgical patient population.

METHODS

We performed a prospective cohort study that included all patients who underwent surgery in an outpatient clinic or hospital operating room and for whom a pathology specimen was sent to the laboratory. The study took place during a 6-month period (October 2004 to April 2005) at an urban, academic medical center. The study's main end-points were the incidence and type of specimen labeling errors in the hospital operating room and the outpatient clinic. The specimen was the unit of analysis. All specimens were screened for "identification errors," which, for the purposes of this study, were defined as any discrepancy between information on the specimen requisition form and the accompanying labeled specimen received in the laboratory. Errors were stratified by the type of identification error, source, location, and type of procedure.

RESULTS

A total of 21,351 surgical specimens were included in the analysis. There were 91 (4.3/1000) surgical specimen identification errors (18, specimen not labeled; 16, empty container; 16, laterality incorrect; 14, incorrect tissue site; 11, incorrect patient; 9, no patient name; and 7, no tissue site). Identification errors occurred in 0.512% of specimens originating from an outpatient clinic (53/10,354 specimens) and 0.346% of specimens originating from an operating room (38/10,997 specimens). Procedures involving the breast were the most common type to involve an identification error (breast = 11, skin = 10, colon = 8); in addition, 59.3% (54/91) of errors were associated with a biopsy procedure. Follow-up was complete in all cases found to have an identification error.

CONCLUSIONS

Surgical specimen identification errors are common and pose important risks to all patients. In our study, these events occurred in 4.3 per 1000 surgical specimens or an annualized rate of occurrence of 182 mislabeled specimens per year. Given the frequency with which these errors occur and their potential effect on patients, the rate of surgical specimen identification errors may be an important measure of patient safety. Strategies to reduce the rate of these errors should be a research priority.

Molecular classification of human cancers using a 92-gene real-time quantitative polymerase chain reaction assay

CONTEXT

Correct diagnosis of the tissue origin of a metastatic cancer is the first step in disease management, but it is frequently difficult using standard pathologic methods. Microarray-based gene expression profiling has shown great promise as a new tool to address this challenge.

OBJECTIVE

Adoption of microarray technologies in the clinic remains limited. We aimed to bridge this technological gap by developing a real-time quantitative polymerase chain reaction (RT-PCR) assay.

DESIGN

We constructed a microarray database of 466 frozen and 112 formalin-fixed, paraffin-embedded (FFPE) samples of both primary and metastatic tumors, measuring expression of 22,000 genes. From the microarray database, we used a genetic algorithm to search for gene combinations optimal for multitumor classification. A 92-gene RT-PCR assay was then designed and used to generate a database for 481 frozen and 119 FFPE tumor samples.

RESULTS

The microarray-based K-nearest neighbor classifier demonstrated 84% accuracy in classifying 39 tumor types via cross-validation and 82% accuracy in predicting 112 independent FFPE samples. We successfully translated the microarray database to the RT-PCR platform, which allowed an overall success rate of 87% in classifying 32 different tumor classes in the validation set of 119 FFPE tumor samples.

CONCLUSIONS

The RT-PCR-based expression assay involving 92 genes represents a powerful tool for accurately and objectively identifying the site of origin for metastatic tumors, especially in the cases of cancer of unknown primary. The assay uses RT-PCR and routine FFPE samples, making it suitable for rapid clinical adoption.

Evidence-based interpretation of liver biopsies

'Evidence based medicine' is a paradigm introduced in the 1990s in which collection of clinical data in a reproducible and unbiased way is intended to guide clinical decision-making. This paradigm has been promulgated across the spectrum of medicine, but with more limited critical analysis in the realm of pathology. The 'evidence base' in support of our practices in Anatomic Pathology is a critical issue, given the key role that such diagnoses play in patient management decisions. The question is, 'On what basis are diagnostic opinions rendered in Anatomic Pathology?' The operative question becomes, 'What is the published literature that supports our anatomic pathology interpretations?' This second question was applied to the published literature in Hepatopathology, by identifying the 'citation classics' of this discipline. Specifically, the top 150 most-cited liver pathology articles were analyzed for: authorship; journal of publication; type of publication; and year of publication. Results are as follows. First, it is indeed true that the preeminent hepatopathologists of the age are the most cited authors in the 'top 150'. Second, the most cited articles in hepatopathology are not published in the pathology literature, but are instead published in much higher impact clinical journals. Third, the pathology of viral hepatitis is demonstrated to be extraordinarily well-grounded in 'evidence based medicine'. Much of the remainder of the hepatopathology literature falls into a 'narrative based' paradigm, which is the rigorous reporting of case experience without statistical clinical outcomes validation. Finally, the years of publication reflect, on the one hand, a vigorous recent literature in the pharmaceutical treatment of viral hepatitis, and on the other, a broadly distributed set of 'narrative' articles from the 1960s, 1970s, 1980s, and 1990s. In conclusion, the discipline of hepatopathology appears to be well-grounded in 'evidence based medicine' in the realm of viral hepatitis. The remainder of our discipline rests predominantly upon the time-honored identification of disease process through the publication of narrative case series.

The Value of Monitoring Frozen Section–Permanent Section Correlation Data Over Time

Context.—The effectiveness of the long-term monitoring of errors detected by frozen section–permanent section correlation is unknown.

Objective.—To determine factors important in laboratory improvement in frozen section–permanent section discordant and deferral rates by participation in a multi-institutional continuous quality improvement program.

Design.—Participants in the College of American Pathologists Q-Tracks program self-reported the number of anatomic pathology frozen–permanent section discordant and deferred cases in their laboratories by prospectively performing secondary review of intraoperative consultations. Laboratories participated in the program for 1 to 5 years and reported their data every quarter. We calculated mean and median discordant and deferred case frequencies and used mixed linear modeling to determine if length of participation in the program was associated with improved performance.

Participants.—One hundred seventy-four laboratories self-reported data.

Main Outcome Measures.—Mean frozen–permanent section discordant and deferred diagnostic frequencies and changes in these frequencies over time were measured.

Results.—The mean and median frozen–permanent section discordant frequencies were 1.36% and 0.70%, respectively. The mean and median deferred diagnostic frequencies were 2.35% and 1.20%, respectively. Longer participation in the Q-Tracks program was significantly associated (P = .04) with lower discordant frequencies; 4- or 5-year participation showed a decrease in discordant frequency of 0.99%, whereas 1-year participation showed a decrease in discordant frequency of 0.84%. Longer participation in the Q-Tracks monitor was associated with lower microscopic sampling frequencies for discordant diagnoses (P = .04). Increased length of participation in the Q-Tracks program was significantly associated (P = .04) with lower deferred diagnostic frequencies.

Conclusions.—Long-term monitoring of frozen–permanent section correlation is associated with sustained improvement in performance.

Classification of error in anatomic pathology: a proposal for an evidence-based standard

Error in anatomic pathology (EAP) is an appropriate problem to consider using the disease model with which all pathologists are familiar. In analogy to medical diseases, diagnostic errors represent a complex constellation of often-baffling deviations from the "normal" condition. Ideally, one would wish to approach such "diseases of diagnosis" with effective treatments or preventative measures, but interventions in the absence of a clear understanding of pathogenesis are often ineffective or even harmful. Medical therapy has its history of "bleeding and purging," and error-prevention has a history of "blaming and shaming." The urge to take action in dealing with either medical illnesses or diagnostic failings is, of course, admirable. However, the principle of primum non nocere should guide one's action in both circumstances. The first step in using the disease model to address EAP is the development of a valid taxonomy to allow for grouping together of abnormalities that have a similar pathogenesis. It is apparent that disease categories such as "tumor" are not valuable until they are further refined by precise and accurate classification. Likewise, "error" is an impossibly broad concept that must be parsed into meaningful subcategories before it can be understood with sufficient clarity to be prevented. One important EAP subtype that has been particularly difficult to understand and classify is knowledge-based interpretative (KBI) error. Not only is the latter sometimes confused with distinctly different error types such as human lapses, but there is danger of mistaking system-wide problems (eg, imprecise or inaccurate diagnostic criteria) for the KBI errors of individual pathologists. This paper presents a theoretically-sound taxonomic system for classification of error that can be used for evidence-based categorization of individual cases. Any taxonomy of error in medicine must distinguish between the various factors that may produce mistakes, and importantly, whether they are individual, small system (e.g., my histology laboratory), or big system (e.g., published diagnostic criteria). Because no overarching governing agency exists to coordinate this initiative, the recognition of need and effective implementation of EAP counter-measures must emanate from our specialty group itself.