Safety—asking the right questions
Thomas M. Sodeman, MD
The 1999 Institute of Medicine report, “To Err is Human,” attributed up to 98,000 inpatient deaths each year to preventable medical error. Those findings fueled a nascent patient safety movement that energized support for quality assurance priorities the College had promoted from its earliest days.
Richard C. Friedberg, MD, PhD, who chairs the CAP Patient Safety and Performance Measures Committee, likes to say that patient safety is the public face of quality assurance. The two concepts are intimately linked, he says, two sides of the same coin. But while “safety” is a buzzword with cultural resonance, “quality” is too abstract; it lacks panache. That’s my impression, too.
Cultural influences are also at play when we talk to other specialists about these topics. Within the medical culture, pathologists have been so long identified with quality assurance that patient safety is no longer what we do so much as who we are. The first CAP national proficiency tests were mailed in 1951, just a few years after the CAP’s founding. The Laboratory Accreditation Program launched 10 years later—six years before the Clinical Laboratories Improvement Act of 1967. SNOMED’s precursor, the Systematized Nomenclature of Pathology, set us on the path to a clear, concise, medical vocabulary 42 years ago. Today, Surveys and EXCEL make up the largest laboratory peer comparison program in the world, the accreditation program sets the gold standard for laboratory accreditation, and SNOMED is positioned to become the universal language for medicine. No surprise, then, to confront the expectation that pathology will have all the answers all the time.
A related challenge is the common assumption that a laboratory report is the final word to accept at face value. People associate pathology with precision down to the third decimal point, and that, in turn, has fostered the notion that a pathology report will always lead to a single correct result. Unrealistic expectations may interfere with much-needed consultation about how the results should be interpreted. We need to inculcate postanalytic consultation as an important step that may be a critical step when we are presenting findings from highly sophisticated diagnostic tools.
As our technical capabilities expand, our communication skills must evolve along with them. A postanalytic consultation is increasingly likely to involve alternative interpretations to consider, further tests that could clarify the diagnosis, and margin for error. Laboratory medical directors must ensure not only that the laboratory staff follows appropriate procedures and provides reliable results, but also that what we learn is thoughtfully communicated so that the clinician makes fully informed choices about treatment alternatives.
The members of the Patient Safety and Performance Measures Committee had all this simmering on the stove when they developed patient safety goals for the College and created the template CAP Laboratory Patient Safety Plan now posted on the CAP Web site.* The patient safety goals seek to improve patient test management processes, including patient and sample identification when specimens are collected, analyzed, and reported. If they’re to be implemented successfully, we will need cooperation from other hospital departments with pre- and postanalytic responsibilities. The patient safety plan template is designed to support laboratory medical directors in taking the lead within their laboratories and their institutions.
We can do a lot of good by fostering the understanding that even highly skilled professionals make mistakes, especially in fast-paced, high-volume environments. Patient care effects are kept to a minimum when a plan is in place to ensure that errors are identified quickly, documented properly, and communicated promptly. A mistake that can be anticipated is a mistake that can be prevented.
The Laboratory Accreditation Program checklists have been amended to reflect the new patient safety goals, and each accredited laboratory is now expected to develop a patient safety plan. The template raises important questions. Are we confident that patient and sample identification routines are rigorously observed? Do these routines extend to when specimens are collected and analyzed, as well as when results are delivered? Are we carefully considering how we report and interpret results that impart life-threatening or life-altering information? Do we sit down to think about how we communicate critical values and how we talk to the clinician about laboratory findings that indicate the presence of malignancy, HIV and other infectious diseases, and cytogenetic abnormalities? Do we take a consistent approach to medical error so that inadvertent events are promptly and appropriately identified, reported, documented, and corrected when they do occur? Have we taken an integrated approach to laboratory patient safety in our institutions, collaborating with nurses, administrators, point-of-care testing personnel, clinicians, and other relevant parties to foster these principles? Have we thought about, and decided, how to inform the patient when a laboratory error occurs? Have we institutionalized the attitude that we need to identify and address the root causes of error so the chances of recurrence are low?
As they told us in medical school, the key to making the right diagnosis is to ask the right questions. The Patient Safety and Performance Measures Committee has done an outstanding job of framing those questions and providing a straightforward approach to a highly complex task.
*To locate the patient safety plan template on the CAP Web site click on References, Resources, and Publications on the main toolbar, then Practice Resources, and finally, Laboratory Patient Safety Plan.
Dr. Sodeman welcomes communication from CAP members. Write to him