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- Title
CLINICAL IMPACT REPORTING AND ASSESSMENT OF NON-CONFORMING EVENTS IN ANATOMICAL PATHOLOGY.
- Authors
DiFrancesco, Lisa M.; LaPerle, Denise; Trotter, Tamara; Duggan, Máire A.
- Abstract
Purpose: Error or Non-Conforming Event (NCE) reduction in Anatomical Pathology (AP) is critically important for patient safety. Since NCEs differ in terms of their Clinical Impact (CI), uniform documentation and continuous monitoring of the rates and types of NCEs and CIs are essential components of a robust Quality Assurance (QA) plan. This studies purpose was to evaluate and revise as needed the existing definitions and reporting of the CI of NCEs captured by the APQA plan in Alberta. Study design: A working group of the Alberta Health Services (AHS) APQA Steering Committee analysed the merits of the existing processes by examining the NCE and CI data of the analytical phase of the workflow pathway captured by 5 of the APQA plan metrics. Results: Gaps in the reporting of the CI of NCEs were found throughout the provincial data ranging from 27% for discordant intraoperative consultations to 33% for revised reports. This highlighted systemic issues with the existing processes and led to revisions which emphasized uniform definitions of CIs associated with NCEs, and provided relevant pathology examples. The revisions were validated using a complete subset of metric 12 (Tumor Board Review Outcomes) data which represented 3 years' worth of Gynecological Oncology data from one of the health zones. The NCE frequency was 24.7% (174/705 cases) and 50% were due to changes in the malignant histotype, stage, or grade. CI assessment of all NCEs was possible and 99% were categorized as "No apparent harm". Conclusions: Evaluation of the provincial APQA plan data led to a revision and clarification of the definitions and reporting of CIs associated with NCEs and were successfully validated in a subset of metric 12 (Tumor Board Review Outcomes) data on gynecological pathology reviews.
- Subjects
CLINICAL pathology; PATHOLOGISTS; QUALITY assurance; WORKFLOW; DATA analysis
- Publication
Canadian Journal of Pathology, 2018, Vol 10, Issue 3, p40
- ISSN
1918-915X
- Publication type
Article