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Of Coping with Error: Eight Guidelines


Mark A. Hurt MD

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[b]Cope[/b]: to face or encounter and to find necessary expedients to overcome problems and difficulties. (Definition 2b on the 3rd sense of "cope." "cope." Webster's Third New International Dictionary, Unabridged. Merriam-Webster, 2002. [url="http://unabridged.merriam-webster.com/"]http://unabridged.merriam-webster.com[/url] (13 Mar. 2012)).

[b]Error[/b]: an act involving an unintentional deviation from truth or accuracy. (Definition 1-b: "error." Webster's Third New International Dictionary, Unabridged. Merriam-Webster, 2002. [url="http://unabridged.merriam-webster.com/"]http://unabridged.merriam-webster.com[/url] (4 Mar. 2012)).

[b]Guideline[/b]: an indication or outline of future policy or conduct.... (Definition c: "guideline." Webster's Third New International Dictionary, Unabridged. Merriam-Webster, 2002. [url="http://unabridged.merriam-webster.com/"]http://unabridged.merriam-webster.com[/url] (13 Mar. 2012)).


You will make errors -- many errors -- in your practice … so many, in fact, that you will not be able to count them all or even know that you made one in many cases. The ones you [i]do[/i] learn about will often send a thrill of terror through your very core, producing more than a few sleepless nights and fearful days.

One of my close dermatopathology colleagues, who died a few years ago, replied, when he was asked whether he had ever made any errors in diagnosis: “hundreds of them.”

If an attorney ever asks you that question on the witness stand, I hope you will agree with my colleague.

Making errors is expected, but identifying potential errors -- both technically and diagnostically -- [i]before[/i] they occur is part of the art of the practice of dermatopathology. Below is a short list of practices that I have developed over the years to help me avoid some of the common errors. Although I did not originate them as such, some of them I employ because of unfortunate errors I have made. Here they are:


1. Always check the accession number on every case against every glass slide. I usually place the slide physically on the paperwork to avoid a mental transposition of numbers.

2. Always check the number of pieces dictated in the gross against the number of pieces of tissue seen on the glass slide. If there is a discrepancy, resolve it before proceeding. I estimate empirically that about 1% of cases have such a problem.

3. If you have reason to believe you are looking at the wrong tissue for a given case, it is an [i][u]EMERGENCY[/u][/i]. Resolve the problem [i][u]NOW[/u][/i]. One method I have used, once the index case is identified, is to pull slides and blocks on two cases that were processed in sequence on either side of the index case in order to determine whether they all match. The sequence of cases does not necessarily correspond to the case numbers. I have resolved countless problems this way -- and it usually works well.

4. If you identify a “floater” (a piece of tissue that is separate from or disparate in the diagnosis from the main tissue) on the slide, you must determine whether the patient’s tissue fragmented, whether a fragment of another patient’s tissue was accidentally transferred into the block, or whether another patient’s tissue floated onto the slide from a water bath in slide preparation. Recuts will, in selected cases, help resolve the issue -- and, perhaps, DNA analysis of the “floater” might establish it as the same or different from the main piece of tissue. Despite the latter scenario, I have never subjected any “floater” to DNA analysis, but I would not be surprised if readers of this have done so. My usual tack is to recut the block, which resolves the issue in most instances. As a rule, if the “floater” is identified in each ribbon of tissue, it is in the paraffin block; in contrast, if it occurs only in one section on one slide, it floated onto a single slide from the water-bath.

5. When you render a histopathological diagnosis, make sure to correlate it with the clinical diagnosis. That “seborrheic keratosis” in a 2-year old is an epidermal nevus or a nevus sebaceus. The “basal cell carcinoma” in a 10-year old is likely a pilomatricoma. "Spitz's nevus" in an 80 year old? -- it is possible, but not probable; look at the sections again. If you are looking at a field of post-surgical scar, and if you see no remnant of the putative lesion, review the earlier biopsy even if you have to retrieve it from another institution; [i][u]NOW[/u][/i] is the time to prove that the original diagnosis was correct and to provide additional documentation of that fact.

6. If you have uncertainty about a diagnosis (and you [i]will[/i] have uncertainty), know yourself well enough to differentiate between the kind of diagnosis that [i]you[/i] don't know versus the diagnosis that probably [i]no one[/i] knows. Consult internally or externally (or both) on any case if you believe it will benefit the patient -- no matter [i]who[/i] is "breathing down your neck," [i]even[/i] at the risk of embarrassment. After all, you have a moral and legal responsibility to provide the best diagnosis you can when you accept a patient's case; you are the patient's advocate, and you can save -- or lose -- his life depending on the choices you make. As a rule, I like to think of every biopsy as coming from a family member to provide me with a heightened sense of responsibility on every case. I am aware also of some dermatopathologists who consult internally on every case; while I have no specific criticism of that practice (provided that it is physically possible even to [i]do[/i] it in high volume practices), it is not the standard of care, and sometimes it can create its [i]own[/i] set of new problems.

7. Check all billing codes against the text of your report; they should match. If not, make sure they do before the report goes out. This not a trivial matter in these days of Medicare fraud audits, and [i]you[/i] are responsible legally for the codes -- not your secretary or your billing department.

8. When signing or releasing the report, first check the name of the patient and the diagnosis against the worksheet rather than the case number (it is important to check the number, too, but you [i][u]MUST[/u][/i] check the name). It is much less likely to misidentify the report by the patient's name than by the number, as there is a tendency to transpose numbers.

Now a final thought about the diagnosis: You will make errors in the process of formulating a diagnosis no matter how careful you are and no matter how many safeguards are in place. Your judgment will fail you in some cases. You will look at cases in retrospect, and you will not understand why you rendered a diagnosis that is just plain wrong. You will not be able to explain it. You will diagnose a melanocytic nevus as melanoma and vice versa. You will confuse lesions of lupus with solar keratosis. DFSP will come off your pen as a dermatofibroma. These things will baffle you, and experience will help prevent it from happening again, but it will not protect you completely -- and it never will.

You are not alone. Share errors with colleagues and learn how to prevent them. You won't regret it.
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Dr. Phillip McKee

Posted

I like this blog particularly as it mirrors exactly my own practice and what I talk about when I lecture on clinicopathological correlation. In addition, I too always tell the residents and fellows to think of the specimen as coming from themselves of one of their family. I also always make sure that when faced with a case with a lot of levels to ensure that I have looked at everyone of them. This can mean counting the number of pieces of tissue befoe you begin looking at them and sometimes if you are disturbed, you have to start all over again. It is the only certain way for example not to miss a nevoid melanoma. Thanks for posting such an important topic.
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Dr. Hafeez Diwan

Posted

A great post! Regarding floaters, we ink successive specimens with different inks. We sometimes get lucky and the fragment of tissue that has floated has a different color ink than the main specimen. Your point about sharing errors with colleagues and learning how to prevent them is a splendid one.
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Dr. Mona Abdel-Halim

Posted

Very great blog,,,, I liked the part of sharing errors,,,,, even experienced dermatopathologists can still make mistakes, it is part of being humans,,, so long as we admit, reconsider, revise the diagnosis, learn, and teach our faults to colleagues,,, and the most important thing is to be humble and don't feel overconfident,, we have to keep learning and reading and revising,,, I liked this blog very much....
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Great blog! Nobody talks about mistakes and how to "cope" with them. So it is very helpful to give a "space" and guidelines to them. And the very important issue is to face them, then how to face them.
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