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Quality Improvement?

Mark A. Hurt MD


What do you think is the best way ensure diagnostic quality in a dermatopathology laboratory? This is a question we have been grappling with and addressing in our laboratory. Of course, all laboratories have to deal with this problem.

There are common sense ways to approach this question. Here are a few that we perform currently:

1. Any case that is reviewed by anyone other than the dermatopathologist of record is referred to in the report, and it is documented so that a report of "multiple sign-off" cases is available. (This is a pre-signed-off review.)

2. Any case requested for review by an outside institution is reviewed by the dermatopathologist of record before it is sent out. (This is a post-sign-off review.)

3. Any case that goes to a clinical conference is presented by the dermatopathologist of record. (This is a post-sign-off review.)

4. Random 1% post-sign-off review by a dermatopathologist who is not the dermatopathologist of record. This is done on cases signed out within the last three weeks. (This is a post-sign-off review.)

When errors are discovered, they are addressed immediately, the clinician is contacted, and a corrected report is generated.

I am curious to know how others do it. Does anyone reading this blog think that the above is an adequate amount of review for quality improvement? If not, why not? What else should be done?


Recommended Comments

Dr. Phillip McKee


A great synopsis of a very difficult subject. When I was at BWH we pretty much followed your protocol with the exception of 4. One point that I might add is that the more pairs of eyes that are sitting around the microscope the better. One tends to think that it is the faculty who teaches the residents and fellows. Not necessarily so!! You are much less likely to miss a mitosis in a melanocytic lesion if many folk are viewing a lesion simultantaneously. In addition, the resident or fellow may be aware of an entity that you sadly have never heard of. This is particularly true for example with connective tissue tumors and then it is the resident or fellow who actually makes the correct diagnosis. This happened to me on a number of cases and rather than feeling embarassed, all I felt was extreme gratitude that we solved the puzzle correctly.
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Dr. Mona Abdel-Halim


I think the most important point in minimizing errors is by allowing many eyes to examine simultaneously ( in our department we examine the slides as a group of 3-4pm a multigeaded microscope) and we all should agree on the diagnosis after enough discussion. Cases not receiving an agreement are left to be reviewed by our senior professor. In my private practice I should reach an agreement with my colleague before settling a diagnosis. Any case not reaching an agreement need to be left for a while, may be we need to read a little more, may be we need to do serial sectioning, may be we need to do a stain,, etc... I think it is all about taking time and doing the job well..
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