Medical Errors - Challenges in Avoiding Them and Resolving Them--and Moving On From Them

• New-in-Practice Resources
• New-in-Practice Committee

Dr. Richard Owings:

Hello. This is Richard Owings. I'm a private practice pathologist in Shreveport, Louisiana with the Delta Pathology Group. And I'm hosting along with Dr. Evans and Dr. Butts, a New-in-Practice CAP podcast about errors in pathology practice. Mistakes happen to everyone and of course, we all want to make sure they never happen. There are whole books written on the subject of identifying and correcting errors that should be part of every lab's quality management plan.

And CAP accreditation is there to help pathologists prevent, catch, and correct errors. However, what's often missed in all this is the worry, the mental effort, and the stress that comes with dealing with errors and then identifying mistakes when they first start in practice. So, hopefully after this podcast, you'll feel a little bit better, have some ideas of what you can do to prevent and deal with errors as they come up.

Today, we'll be discussing errors with two additional New-In-Practice pathologists to get their perspective. Today we have Dr. Juanita Evans from Michigan Diagnostic Pathologists and Dr. Yasmeen Butt with Mayo Clinic. Hi, guys. Why don't you go ahead and introduce yourself and give us a little introduction?

Dr. Juanita Evans:

I'm Juanita Evans. I'm a private practice pathologist out in Detroit metro area. We're a group that covers two community hospitals with pretty strong degree of residency and fellowship programs in fields other than pathology. And although all of us do surgical pathology, in general, my specialty is hemepath and I've been practicing now for, I think, nine years.

Dr. Richard Owings:

Great.

Dr. Yasmeen Butt:

Hi, everyone. My name is Yasmeen Butt. I am a pulmonary pathologist. I am out here at Mayo Clinic in Arizona. I also sign out general pathology. And we don't have a residency either at our program but we certainly have quite a few people that are rotated in our department from other specialties as well as visitors from outside of Mayo Clinic.

Dr. Richard Owings:

Great. Well, I'm glad we could all get together to do this. To everyone listening, all three of us are part of the New in Practice Committee through the CAP. And so, this comes up quite frequently in our committee meetings and it's something that when we talk to people at the CAP, New in Practice people in particular are always worried about making errors as we discussed. So, we all thought it would be a good idea to discuss this. So, let's go ahead and get started.

I'll start out with asking you each a question. When you guys were starting practice, was there a difference in what you thought type of errors you might be making or what you're worried about? And what you're actually finding now that you're in practice?

Dr. Juanita Evans:

I would say-

Dr. Richard Owings:

Dr. Evans.

Dr. Juanita Evans:

... 100%, absolutely. There's a huge difference. When I first started out, I thought maybe I would pull off the wheels and just start flying immediately. And then, suddenly, I was worried about everything, down to the humble tubular adenoma and basal cell carcinoma. So, the stuff that I thought I need to worry about like diagnosing big cancers on resection, that wasn't the big deal.

Everything was a little bit scary to me. I had to come up with a system and a plan to not let it hamper me too much and still put out quality work at the same time in an efficient manner. So, I would say a 100% did not expect what would actually scare me when I first started.

Dr. Yasmeen Butt:

Yeah. I'll second that completely. When you have the really difficult cases, you know that that's a case you need to share. It's all the so-called ditzel specimens, I think, especially in the beginning that cause you a lot of stress. Because as a resident you weren't thinking about, "How do I phrase this hernia sac biopsy report?" because that's so-called easy. But then, all of a sudden, when you're signing out cases, it's the little things that can trip you up.

Dr. Richard Owings:

Yeah. I'll second that for sure. You mentioned tubular adenomas and hyperplastic polyps. I think my first week I showed about 10 of those. Do you agree this is a hyperplastic polyp and non-serrated adenoma? It's just kind of the bread and butter stuff that I worried about.

When I was starting, I was worried about a sarcoma or some rare lung condition or inflammatory condition and that's not usually what I find people make mistakes on because you know that's what you don't know and stuff.

Dr. Juanita Evans:

Right. So, you mentioned you were able to show your stuff around, you just feel like your group was pretty amenable to being like, "Hey, I know this looks like it's a nothingburger. Can I please show it to you anyway?" Or did you have to find particular people in your department who were cool with that?

Dr. Richard Owings:

Yeah. So, I'm actually part of a pretty big group of about 50 pathologists. Though were spread out across the whole State of Louisiana. So, where I initially started practicing, we had three pathologists locally and they basically told me on the front end, "We expect you to show..." Well, for the first two weeks I showed a 100% of what I was signing out before I signed it out. And then, after that, they said probably 50% to 40% of the stuff that I would be signing out, I would be expected to show. And then, after a few months, it was all new malignant cases.

And then, after six months, I was pretty much flying solo. Though I still think today I show about 15% to 20% of what I sign out.

Dr. Yasmeen Butt:

Yeah. I think that's really reasonable. Especially when you start practicing, in the very beginning, you're going to want to share if not everything, almost everything. And that's just so you learn where your comfort level is and where you actually are. And it's very different when you're actually signing out your own cases compared to be a resident. And I think everyone has different levels of comfort with different areas.

So, for example, if you did a fellowship day in hemepath or pulmonary pathology and you go into a general practice, you're probably going to be okay signing out your subspecialty area. But that might be the first time you sign out that tubular adenoma or that hyperplastic polyp and you may want to share all of those just to make yourself feel a little bit more comfortable. And I think it also depends on how much autonomy you had as a fellow or even if you didn't do a fellowship, that's rare these days but it can happen. So, cut yourself some slack. And I think err on the side of showing something rather than not because the only person that stands to lose is the patient whose biopsy that is.

Dr. Juanita Evans:

A 100%.

Dr. Yasmeen Butt:

So, always share your cases when in doubt or even when you're just slightly in doubt.

Dr. Richard Owings:

Yeah. Actually I noticed when we... So, I've on boarded now probably three or four pathologists that I've been involved in, brand new people we brought in. You can feel the tension because they don't want to be, I guess "lame" by showing all their cases. And so, they'll always apologize for showing me... I'm a breast pathologist, so showing me what they think is easy breast cases. But invariably, there's something that I can add to their report or even point out things like, "Oh, the clinicians are going to want you to report this. Just because you're new, you don't know what the culture is there and what's expected in that local market."

When I'm working with a new pathologist, tell them that we expect them to show everything initially. Over the course of six months or so, that'll scale back down as they get more comfort but never to hesitate showing anything. And the other thing I tell people is if you show me a case that you think is weird and I just blow it off, you may be right, I may be wrong even though I've been here a little longer. When I first started out, I had a couple of cases that I showed to the partners and they have said, "Oh, this is nothing to worry about," but I was still uncomfortable with it. I sent it out.

Or they said, "Oh, this is so rare. It couldn't be that." So, I ended up sending it out and ultimately, I was right and I'm glad I showed it. But one example I had was a Hodgkin's lymphoma in a pelvic mesh that was CD30 positive and it was really bizarre and I showed it around. And people were like, "That's not what this is.

It's just some inflammatory thing," but it was strongly CD30 positive. And so, I was like, "I'll just send this out to be sure." And they did an EBER stain and then that was positive. So, we said, "This is probably Hodgkin's." And it turned out the patient had diffuse adenopathy and they biopsied the lymph node and they had Hodgkin's.

Dr. Yasmeen Butt:

Oh, my gosh. That is you paid [inaudible].

Dr. Richard Owings:

So, yeah. So, you just keep digging.

Dr. Juanita Evans:

I 100% agree with that. That whole trust your gut, good you trusted your gut to show it the first time. But if you're still not satisfied, maybe it's okay to get a second, second opinion and there's something wrong with that.

Dr. Richard Owings:

Yeah. There's nothing wrong. And the partners were fine with that. When I said, "Well, I'm still not comfortable. Do you mind if I send this out?" They're like, "Yeah, sure. Send it out."

Dr. Juanita Evans:

Yeah, I think it's really cool how your group really set those expectations for you, what they expected you to do for showing. I'm coming from a totally different perspective. There were no expectations set. So, I joined this group. I only knew them from the interviews.

You first get there, "Who are these people?" And they're probably thinking, "Who are you?" As long as it shows you to work with him. I think on the backend, without them telling me there was a 100% review of cases that I had signed out before I signed them out, but there was nothing up front. But I knew the culture felt very welcoming.

So, I definitely just showed all the time and certain people were definitely utilized more often than others. And I think the one thing to take out of that is no matter where you practice, even if there is an expectation set, you can try to help develop the culture that says, "Hey, I'm going to show you cases and feel free to show me cases."

Dr. Yasmeen Butt:

I think that that's really important, especially when you're looking for your first job to find out what those initial quality control programs are or if they are in place. And if they're not planning on looking at all of your cases after sign out to even ask them to on your own volition. When I started at my first job, which is where I trained, they actually didn't have anything set up in place to review my cases. Now, I trained there and so I knew everyone and I showed most all of my cases anyways. So, I think it was a moot point.

But when I started my second job here at Mayo, I know that they had retrospective review. I think of, it wasn't all of my cases, but it was like the first 60%. It was some huge percentage of my initial cases that they signed out, that I signed out, that they reviewed to see if there were any discrepancies or any concerns before they set me loose so to speak. But still, I shared a ton of cases. So, I think if you're new in a job or even if it's not your first job in the type of way you're signing out, that was something that was different for me.

So, my first job was subspecialty. So, I trained in thoracic and I only did thoracic and I did that for two years. And then, when I changed over here, now I sign out general. And so, even though I'm in my fourth year of practice, I've really only been signing out general for one year. And that's a whole new thing, especially with a couple of years in between of not looking at anything outside of thoracic.

So, that's something to consider too. You may not be super new in practice, but you may be new in practice to what you're signing out if you're changing jobs. And it's not uncommon for people to change jobs one, two or three times in the first 10, 15 years of their practice until they find something that really fits with them. And then, also it's just chance and geography.

Dr. Juanita Evans:

I was going to say, just to throw on that. And it's not just being maybe new to the thing you're doing in your current job. It's also being new to how people sign out, any particular kind of case. Because there may be some local flavor to how you sign out a tubular adenoma or the breast case or whatnot. It's really good to have that shared early on and not later on when all the clinicians are calling at you mad that you didn't word it the way they're used to seeing.

Dr. Richard Owings:

Yeah. That's actually a really good point. One of my colleagues that works in another market, before he came to us, he actually did a lot of moonlighting in different practices.

And what he said he started doing because he do these locum tenens jobs when he would show up, he would just go through the last two months of reports. He'd pull up and just see how they were signing out cases to know the verbiage they were using or if they were using some weird dysplasia grading system, just cervical biopsies, they may sign them out slightly differently or may not be up on the latest terminology. And he could modify his reports to be in line with what everybody else had.

Dr. Juanita Evans:

So, we talked a lot about review of the regular bread and butter cases. How did you practice handle like frozen sections? What did you do when you first started when you were doing interop?

Dr. Richard Owings:

Yeah. So, for me, the first couple of weeks to a month they did a 100% where they would come up and first they did the frozens and we looked at them together. And then, I would do the frozens and they would still be there. And then, they're always a phone call away. And they would expect me to call them up to help or I'd have a tech run down a frozen section like a brain neuro frozen or something like that to start. And then, of course if there were any mistakes made on frozen section compared to the permanent, then those got brought up immediately the next day.

But I did have a couple of cases where it'd be some weird brain case I'd be looking at it and I'd call the tech and have them run upstairs to grab the slide and bring it down to the other pathologist before I was signing out on my own or frozen. But how about you guys?

Dr. Yasmeen Butt:

I think for me, my first job, I didn't have anyone there with me, so I spent a fair amount of time dashing to people's offices to share cases on things that I wasn't sure about and it worked out okay. But occasionally you're alone on frozens oftentimes, and so you have to pull the trigger and do the best you can. I would say as a general piece of advice on frozens is don't overreach yourself. Don't make a diagnosis that you're not sure about. And if you're not sure, just let the surgeon know.

"I'm not sure. I think it could be this. I think it could be that. Could you give me more tissue? How is this result going to change what you're going to do?" and just talk to them.

I know that can be scary, especially for pathologists which tend to be introverts to actually have that engaged conversation with the surgeon. But I think it's really important. Where I am now, I have the luxury of always being on frozen with someone else, and that's just how our system is set up. We always have two people on frozen desk every day. So, you always have a built-in person to showcase this to, which is really, really nice.

I really like that. And then, of course if there's any discrepancies afterwards, we always take it to the person. If it happens to not be your case, usually the case will go to you. And then, we track those metrics and send them out every month if there's any frozen discrepancies.

Dr. Richard Owings:

We actually have a QM program, our QA function for frozen, so it's agree, disagree, minor disagree, major. And then, we've got deferral appropriate, deferral inappropriate. We do occasionally have people that will defer every single frozen, and so we actually can catch that before the surgeons complain. So, I talked to a surgeon one time and he was complaining about another pathologist. Everything is equivocal or deferred, that pathologist just didn't want to be wrong.

So, they would hedge everything. So, it'd be benign. They'd say, "But can't exclude cancer." And that's technically true, but to the surgeon, they read that as they're just not making a call. And in the OR they have to make a decision on what they're doing and they understand.

He says, "Look, I know you guys are going to make mistakes, but I have to be able to operate confidently." So, anyways, we have this deferral inappropriate, which is not use that commonly. But if it's somebody else could have made the call or feel like. But usually they'll come to you and say, "You could have made the call here or something like that."

Dr. Juanita Evans:

Sometimes it's just terminology. I have a story about that. When I first started my current job, I would put my frozen section diagnosis and then I would say oftentimes defer to permanent for final classification or something like that. So, I wasn't really deferring the diagnosis, but I had the word defer in there. After my first couple weeks, someone nicely told me, "Be careful about using that because we almost never defer any of our cases and all of a sudden our percentages have gone way up because of your terminology." So, that also ties into just knowing how people sign things out, including on the frozen section bench.

Dr. Richard Owings:

That's right. But that's someone that's training because I know they're appropriate. They say everything is deferred on the permanent. Some practice cultures that's assumed as part of the frozen. You know?

Dr. Juanita Evans:

Right.

Dr. Richard Owings:

But anyway, so that's I guess talking with your colleagues.

Dr. Yasmeen Butt:

Yeah. And also frozens are just difficult. I'll tell one of my stories that I keep oscillating on is what to do about sentinel nodes. Where I work, one of our hospitals, you're solo, so just good luck with a frozen one when you can get it. And the other one there's people around so you can show. So, my deal with sentinel nodes is now that when you're trying to cut them sub two millimeter, you're starting to get a butt load of cassettes and then there might be three or four and the container.

And I'm like, "I can't freeze all of that." And so, I was doing this really elaborate procedure of touch preparing and scraping and freezing one of each or whatever. And then, I finally missed a sentinel. And I was just devastated because every frozen feels like a huge loss on the battlefield when you miss one. So then, I went to freezing every single block.

I mean sometimes eight blocks of lymph node and that's also clearly ineffective because it takes forever. It decreases the utility for frozen when it takes 40 minutes to get the full answer out. So now, I'm back to touch prepping, scraping, cutting, you know what I mean?

Dr. Richard Owings:

Yeah.

Dr. Yasmeen Butt:

Frozen are so difficult sometimes. And there's no way you can be like, "Hey, guys, no one has eight microtomes, so eight people can help you cut frozen."

Dr. Richard Owings:

That's right.

Dr. Yasmeen Butt:

You know what I mean? I don't know. Just to put it out there, sometimes you just can't. Sometimes you just can't win.

Dr. Richard Owings:

Yeah. Actually speaking of breast sentinel nodes. So, sometimes people, because I'm a breast pathologist, people will ask me what to do with those. Because they're always worried about missing a med and really you just want to make sure you don't over call a med because you can't put the axilla back in once it's been taken out. And so, I had a case, one of my partners signed out frozen as positive for adenocarcinoma. And then, I got the permanence on the sentinel nodes and also the breast.

And the breast cancer was high grade and the node looked very low grades. These little tubules. And if you look at them, they had these little apical snouts and maybe axilliated bar or terminal bar with axilla. And so, I stained it and it was endosalpingiosis and the sentinel node on frozen. And so, I went and showed the pathologist like, "Well, this is actually endosalpingiosis."

So, technically it's an error because it was called metastatic on frozen, but I didn't know how to categorize that. Is that an error or would every pathologist that look at that call that metastatic adenocarcinoma?

Dr. Juanita Evans:

Right, right. Yeah.

Dr. Richard Owings:

Yeah. I think we called it a minor disagreement and then I put a comment in the report explaining. And I talked to the surgeon about it and they were fine.

Dr. Juanita Evans:

That's like a [inaudible]. That's rough. Look for that original pathologist.

Dr. Richard Owings:

Yeah. That's an error that is going to get made every single time. And it's like that error is set up by doing a sentinel node to begin with. That you just happen to catch that one. Because he felt really bad about it. And I was trying to explain to him was like, "There are things you could know on the frozen had you had the biopsy and you would know it looked different. You could maybe have said, can't rule out endosalpingiosis but that wouldn't help the surgeon."

Dr. Yasmeen Butt:

Get lucky and notice it or something.

Dr. Richard Owings:

Yeah.

Dr. Juanita Evans:

I was thinking that ties well into, so what do you do? You made an error or someone thinks you made an error, what's the next steps? Have either of you been in that situation? Because I could say a 100% I haven't been in that situation before.

Dr. Richard Owings:

Yeah. So, in my group we have basically an error thing. So, if we say it's a major diagnostic disagreement on the frozen, then we have to document a call to the surgeon and we put it in a comment of the report. Usually the surgeons are very gracious about it.

They understand there are limits, particularly the frozen. Now, that's on frozen. Now, if it's something in the report that we pick up on retrospective review, then we do that with a corrected report. But a frozen, we just deal with it in a comment in the original report.

Dr. Juanita Evans:

Yeah, I think the same thing with frozens. I think that goes back to a CAP or CLIA standard to call any major disagreements. And I agree most of the time they understand and most of the time it's sentinels. Ooh, of course.

Dr. Yasmeen Butt:

Yeah. We have a similar protocol. If there's a discrepancy and it was a real missed discrepancy, of course we'll communicate that to the surgeon and have it in our report as part of that original report that there was a discrepancy and why that was. It always feels really terrible when it happens to you. Hopefully it doesn't happen that often. It's happened to me once or twice.

And it's always just your stomach drops out when you're like, "Oh, no, I made a mistake." And whole surgeon let them know that this margin in fact was either positive or negative or something. But you just want to get it out there as fast as possible and learn from the mistake if you can. We will often share our errors at our AP meetings, devoid of information of who it was. No one has to feel embarrassed just so you can make something more out of that mistake.

A mistake happened and mistakes will happen. So, I think it's best to share it as much as possible. So then, you might help someone else avoid the same mistake.

Dr. Richard Owings:

So, do you guys show the actual case to people? Do you have pictures or something so they know what everybody was looking at or you just said sentinel node miss? Or how do you guys handle it?"

Dr. Yasmeen Butt:

The actual cases. So, it's a voluntary thing. But if you have a case that there was an error made or something that you think would be worthwhile to submit to the whole department, we'll scan the case and I'll send it around. And everyone will have a chance to look at it. And then, we'll have that meeting and we can talk about it.

And if there's some particular point that was specific to a particular system, the GYN person who will say, "Hey, this happened and this is why this happened. So, just for everyone else to keep in mind." But it's nice because then you can actually look at the scan slide.

Dr. Richard Owings:

Yeah. It's almost like a pathology M&M Conference like the surgeons have.

Dr. Yasmeen Butt:

It typically is I mean that's what we call them.

Dr. Richard Owings:

Oh, really? Oh, okay. That's actually a really good thing to have I think because you hate to make a mistake. But it's almost, you really don't want to do it a second time.

Dr. Yasmeen Butt:

And you're making the most out of it. It happened, it wasn't good, so try to get as much good out of the bad as you can.

Dr. Richard Owings:

So, that was frozens and stuff. How do you guys arrange your quality programs? So, you catch errors, you might show all new tumor cases, but how do you catch errors that you might not be aware of, like a signet-ring cell carcinoma and a gastric biopsy or something like that?

Dr. Juanita Evans:

Well, I'll jump in and say that not everywhere too is all new malignancies. We have been evolving our program over the years. When I first started really it was self-driven. You had to have your own processes in place. For example, this is not even as serious as a diagnostic error, it's just does my paperwork, match my slide, match my computer like that.

And then, you might have it in the back of your head also gastric biopsies to think about signet ring. And then, we had an audit system where if you did have a question or you just wanted to learn about wordsmithing or whatever it might be, we could send that around. And that was our formalized process for having input and reducing errors. But we now as of the last year, we switched to a formal process where all new malignancies are shown in a pathology review conference. And I've actually super love it even though I've been practicing a few years, I get to see a lot more of the cool cases that are running through the department.

And everyone can learn from one another and another level of stability like, "Yeah, okay, I'm not crazy. This is cancer and everyone agrees." Or vice versa because you can bring any case you want to to that conference. So, just to throw that out there. My practices change.

Dr. Yasmeen Butt:

We don't review every new malignancy by policy here, but we do have a retrospective review. I think it's something like 10% of all of the cases. And so, every day you'll get a green folder that has essentially a random case that was signed out within the last couple of weeks to review. And so, those are just randomly assigned to everyone. So, it gives a broad swath of what's going on.

But I like that idea of having a conference and everyone shows all of the new malignancies for the day. We're not quite set up to do that, but I think that might certainly be helpful.

Dr. Richard Owings:

So, we don't do it like a conference. We try to do have two pathologists review all new malignancies. Sometimes you're at a remote site or something and it's obvious and it might not make it to that. But in general, so like all new breast cancer biopsies that are for cancer, prostate will typically get reviewed. And then, we do a 5% retro review.

We're just randomly pulls 5% of cases and distributes some equally amongst the pathologists. And that's how we catch the stuff that you don't know what you're missing because you should randomly pick that up. And then, we actually compile that into a large report that get sent out to all the pathologists and it actually has our initials. So, you actually see how many corrected reports you had and actually everybody sees it. So, we kind of know.

Well, I think there was some resistance to setting that up initially. Oh, it predates me. The transparency for errors I think is important because it's embarrassing. And the worst thing in the world is to hide it and then not deal with it because it's really for the patient care. That's all that matters.

Our feelings don't really matter. They do matter, but they don't matter in terms of patient care. Yeah, okay. Well, Juanita, you mentioned about catching stuff with mismatched paperwork and slides. I'll get a slide that's mislabeled down in histology.

You don't have a tray of slides and they put the wrong slide on the tray. And so, I'm looking at one case and at the end there's the wrong biopsy and I'll pick that up and start looking at it. And usually you catch those. We always worry, "Am I going to pick that up and dictate it?" Has that ever happened to you guys?

Dr. Juanita Evans:

Yes. And I mean I can say for sure in the last year I have signed out the wrong knee on the wrong knee patient. I have definitely done that and I think part of it is just trying to be ever vigilant. Those kinds of mistakes happen to me more often when I'm tired at the end of the day. So, I have to always remember, think a little harder. Because we don't have a bar coding system here.

So, we really do have to be diligent and match it. But like you said, you always notice it because the next slide you pick up is something different and out of order, so you can immediately issue that corrective report and fix it. But yeah, I mean that happens. You hate to do those kind of errors just because they're so simplistic, but could be significant at the same time. Because if you put the wrong diagnosis on the wrong patient, oh, my gosh, what could happen if you didn't catch it?

Dr. Yasmeen Butt:

It's the worst kind of error that can happen. You can make the most brilliant diagnosis, the most difficult case, and then you give it to the wrong patient. And there you go. I'll say that our system is nicely set up in the sense that we only have one case per tray, which can lead to a high number of trays when you're on biop. But I really like it because it greatly decreases the chances of making a mistake and dictating a different case.

We have barcodes on our paperwork but not on our slides, so that is one potential bot of error for us. I always make sure to double check that the name on the slides is the same as the name on the paperwork. I think our different examples just highlights how you have to analyze your system where you are because everyone is going to have a slightly different system. And ask yourself, "How could I make a mistake? Where is the spot where I'm going to make a mistake?"

And just try to set up your own personal way to avoid those mistakes. Like for me, right before I hit the final sign out, I always have the case in front of me. I try not to sign out cases unless I actually have the slides with me. And I just glance at the slide, see the name on the slide itself, not the paperwork but the slide because for me that's a point of error. Because I don't scan the slides, I scan the paperwork and look at that before I sign it out.

Dr. Juanita Evans:

I'd also say I look for names that are very close or the same. I always check my queue for that. And if I come across that name then I'm like 3,000 times more careful. I make sure the name matches the date of birth, matches the site, everything matches appropriately because that's a problem I've had in the past too.

Dr. Richard Owings:

I'll have a day where I might... because we're subspecialized, so I might read 15 or 16 breast biopsies in a day and they're similar cases and they're spaced out. So, what we have to do is we actually ink the cores different colors. And so, in a cycle you'll have nine or eight colors, I guess. It'll be grossed as ink blue, the slide will be blue, and then there's a popup right before I sign it out that says, "Core ink blue does this match?" So, it's a blue core, green core, red core, a yellow core.

And that actually cuts down. I think I've had two cases where the correlation didn't match. Both cases were actually, they just misdictated the color and we're able may have a log where they actually put it down or it gets transcribed incorrectly or the transcriptionist mishears it. But that way it all matches when you're signing the case out. And also if histology flip-flops a block or something like that, you'll have a color mismatch.

Dr. Juanita Evans:

That's really nice.

Dr. Richard Owings:

Yeah. So, that works pretty well. And then, with breast biopsies, our lab can mix stuff up, which we have control over, so we're responsible for that. But I've had cases, and I've heard about bad examples in other labs where the lab did nothing wrong, but the radiologist doing the core biopsy, like doing breast biopsies for instance, their nurse flipped the containers. They print out a label from the EMR, put it on the wrong container and then they send it down. And there's really no way to catch that error.

When I was a fellow doing my breast pathology fellowship, there was a case that came through right before I got there of a 30 something year old lady who had a bilateral mastectomy for a microinvasive DCIS. They took the breasts off and there was nothing there. There was no tumor or anything. And so, it came to our service as a consult because they said they can't find cancer. And we looked at it, the lady had had a 14-gauge core biopsy of a mass.

And the biopsy we had with her name on it was a big fat core, like a nine-gauge core biopsy with calcifications with DCIS. So, it was actually at an outside hospital. So, they called and there were two biopsies done that day. One for mass, one for calcifications, and the nurse had flip-flopped them. And so, the pathologist basically misdiagnosed the patient, but on a pre-analytic error.

And so, the moral of that story is if you're really looking at the gauge of the needle and make sure everything fits mass for mass, calc for calc, you can prevent an error, but you really have to be paying attention.

Dr. Yasmeen Butt:

Yeah. That's a horrifying example. Hard to catch those types of errors. I think it nicely illustrates how you just need to be aware of everything around you. And you never know what might key you into the fact that there's a mistake. You know what I mean?

So, just be aware of the patient's history, the specimen, and sometimes you don't have as much history and it also depends on your practice environment. I think in some places if you receive biopsies done elsewhere, you may not have access to their clinical history, but you just look for things that don't quite make sense.

Dr. Juanita Evans:

Yeah. I have a similar story to that one where a patient was having some endocervical endometrial keratosis done in our ORs. And one of the curettages came down later attached to that patient and it was cancer. And we said, "Oh, yeah, you have cancer."

Turns out mislabeled the jar and it belonged to the second patient in the room. And it's just in retrospect, if someone would had noticed, "Well, why did we get a second curettage an hour later?

It should have come down with the first one." That could have been assigned to, there may be a pre-analytic problem. But those pre-analytic errors are just very difficult to catch overall.

Dr. Richard Owings:

Catch. And I think they're actually a major source of errors occurring in labs. So, things that occur before the lab. That's also true in the clinical lab. It's usually pre-analytic, either specimen labeling or some problem with the original sample. The other area that I've noticed has got a lot of problems is when a hospital switches EMRs.

So, their processes are changing. So, we had a system printed labels one way. And then, they switched to another EMR where they were printed out a different way and the nurses had to actually do the requisitions in the computer. And the printers were going down, so they were having to go to a central location to get the labels. And then, three nurses were all printing to that and they would get the labels.

Nurse A would grab what nurse B had printed and vice versa, and they'd come down and it'd just be a total mess. And so, after going through that, when you go through these high risk situations like an EMR upgrade or transition, you really have to be involved in making sure that people, you never think about as pathologists, the nursing staff or the orderlies or whatever, or the techs are doing what they're supposed to be doing and are trained well. When we went live, I remember I was up in the endoscopy suite educating the nurses exactly what had to be done on the requisition for days.

How about the post analytical? So, we've talked about pre-analytical. We're talking about diagnostic errors, analytical. Have you guys had any experience with errors occurring after the case assigned out either doctor's not understanding your reports or your report is not getting to where they're supposed to be?

Dr. Juanita Evans:

A little bit. I would say sometimes it's like the phone game. So, for example, say I get a bone marrow and I see something that could be a lymphoplasmacytic lymphoma or a marginal zone type lymphoma, we just can't really tell. It was a long time ago. We don't have an MYD88 to help prove it.

Well, I had this one patient where, I don't know why, because it was find out as lymphoma, low grade, can't tell you what it is. And the patient somehow got carried the diagnosis of marginal zone lymphoma for 10 years or something like that. And then, they get a new marrow because they're like, "Well, they have a really high IG paraprotein. What's going on here?" And it's like we do the MYD88 and you're like, it's lymphoplasmacytic lymphoma.

Dr. Richard Owings:

Oh, wow.

Dr. Juanita Evans:

They're Like, "Well, why did the diagnosis change?" It's like, "That wasn't the original diagnosis. I don't know what to tell you." Where did the miscommunication happen in that chain gain? I don't know.

So, that's more so. And I guess it's an error for sure because the patient thought they had one thing and not the other, but it wasn't misrepresented in communication or paperwork, at least pathology report.

Dr. Yasmeen Butt:

I think that's an example of something I've seen before about a misunderstanding of a pathologist report. We sometimes have complex reports and if a resident or even a medical student or someone doesn't quite understand the diagnosis, they may pull something out of it. If they do understand and type it in a note. And with the advent of electronic medical records, everybody copies and pastes. And so, I can't tell you how many times I've seen in records where I see someone wrote, patient has cancer X.

And I'm like, "That's a really odd diagnosis. That doesn't really quite make sense." And I dig back and I dig back and sometimes you go back a long time. Or you try to find the original pathology report and you're like, "Oh, they don't have that at all." I think it's important that clinicians read the original reports.

And then, if you're following up on a case or you have additional material on a case that I never trust what's written in a note. I always want to see the actual report. But I think there can be problems with perpetuating errors in the medical record based off of a lack of understanding of a pathology report.

Dr. Richard Owings:

Yeah. So, in breast pathology, there are pathologists that will sign out DCIS or ductal carcinoma in situ is intraductal carcinoma, which is abbreviated IDC. And then, invasive ductal carcinoma, which is an invasive process is IDC. So, I was in a breast conference one time and they said, "This lady has invasive ductal carcinoma." And I looked at the report and I was like, "This is in situ carcinoma." So, they just misunderstood the report and the surgeon had been told by the resident what they had and nothing added up.

And so, after that I said, "Okay. We're not going to use intraductal carcinoma anymore." We just need to use ductal carcinoma in situ and DCIS because the way surgeons abbreviate it is confusing to them.

Dr. Juanita Evans:

And I think that points out where a good rapport with your clinicians and your surgeons can be really helpful so that you make sure that you are communicating your words in such a way that they understand exactly what you mean and those kinds of mistakes don't get made up.

Dr. Richard Owings:

Yeah. I mean there's just so much information coming at them that the surgeon or the medical oncologist is trying to put together. And you might have bits coming from this lab and that lab. And our reports and our pathology labs look very good. But then, when they might cross over to some hospital EMR, the formatting is weird, the synoptic gets cut off in a weird spot or somebody uses some weird character that is not recognized, and so all the reports have question marks in them. So, that's all something to be aware of.

Dr. Yasmeen Butt:

I think it's important to know how your report looks like in the EMR because we have the same thing. So, you can click on our reports and you can see the PDF. That's the nice version that we sign out. But if you actually just look in the text of the EMR, it migrates it over and it doesn't look very nice. And I just also wanted to add too, I think your comment about the IDC and it's a different abbreviation is why it's so important never to use an abbreviation in a pathology report. I was trained early on and it's just never use an abbreviation in a pathology.

Dr. Juanita Evans:

What do you guys do when you have a case that's been sucked out and it comes back and maybe it's a little bit different from what you called it or graded it? Or how do you handle that kind of stuff? So, maybe not a major error, but a stylistic change.

Dr. Richard Owings:

You mean internally or if it goes out to a referring institution?

Dr. Juanita Evans:

I guess both matter. Someone sees it for a tumor board and they go come back to you and say, "Ah, I thought it's grade two, not grade three," or I don't know. Yeah, I think both situations happen.

Dr. Richard Owings:

Yeah. So, it depends I guess on exactly what it is. They're bringing it to my attention. It's usually more than something minor. One, if I recognize it and bring it to them or they recognize they bring it to me, we usually bring it to a third or fourth pathologist and have them review it and they get a consensus. But I think the most recent example I've had of that was is this a papillary microcarcinoma in the thyroid or is it just some weird little follicular nodule that's benign? It just has some incidental clearing.

We had four pathologists say one thing, five pathologists say another. That case got sent out. Of course, I was the one sending it out. So, I was like, "Okay, who's going to agree? Which consultant is going to agree with me?" But yeah, so that's how we handle it. So, if there's any type of diagnostic thing like that, we'll show it around to other pathologists, get a consensus diagnosis. And if we still can't reach consensus, then we send it to another institution.

Dr. Yasmeen Butt:

We do the same thing. I mean, thankfully it doesn't happen very often, but if it does, anytime there's a disagreement, the first thing you do is share it with someone else. And then, if you can reach in a consensus with that person, then that's great. But I think ultimately it's important to convey to the patient's clinician why there's a discrepancy and how it was dealt with and whether or not it's an area that's murky. So, like a Gleason three versus a three plus three versus four plus three, share it with another person and whatnot.

But if it's a major discrepancy and you still can't get agreement even after sending it out, you may get conflicting opinions. Those are really challenging cases. I think it's important to convey that challenge to the clinician. So, they understand that maybe they need to get another biopsy or maybe they need to follow the patient a little bit more closely depending on what the issue is.

Dr. Juanita Evans:

Yeah. I also find that sometimes the things that we are getting tripped up on aren't necessarily going to make a change in management. So, once again, getting back to that clinician could make a big difference in how you handle the case.

Dr. Yasmeen Butt:

Yeah. Ultimately it comes down to what's important to the patient, will it change if the patient gets treatment or doesn't get treatment.

Dr. Richard Owings:

So, we're getting close to the end here, you guys. There's one thing I'd like to talk about. So, how you catch errors is important and finding the errors, but one of the most stressful things that I've found is talking with my colleagues about it. Particularly when I was in my first six months to a year, I might find something that I either I disagreed with or the terminology was funny. But I was a little bit timid about going to somebody and say, "I think you made a mistake."

Because there's this power dynamic and you don't know how that person is going to react to the young pathologist saying, "I think you made a mistake." And they've been practicing for 20 years. So, how did you guys approach that when you first started out?

Dr. Yasmeen Butt:

I think I am a little lucky in the sense that our review process is anonymous. So, you can of course look the case up and see whose case it is. But the way we send the cases out is we don't have the name of the signing pathologist, so you can just write your thoughts on it and send it back and never know who it was. But I agree, I think it can be really difficult to show something to someone that you may disagree with. But I think it's important to do that and to realize that even as someone new in practice, or even when you were a trainee, you may have a thought or you may have looked at it in a different way that perhaps someone with even quite a bit of experience either didn't see or they were tired or they missed it.

I mean, no one's perfect. We all make mistakes and we'll continue to make mistakes. As much as I wish that was not the case, it will happen. So, I think it's always important to speak up. And just as with everything, you don't need to be antagonistic about it.

Just say, "Hey, I might be wrong and maybe you can help teach me something, but I did see this and I was worried about it or concerned about it. Do you mind taking another look and we can talk about it?" I think that's really important because like we've been saying throughout this whole podcast that it always comes back to the patient. And I think anytime you are worried about something or you have a question if, "Should I have someone look at this? Should I review this?

Should I bring this up?" The answer is, if this was my biopsy or someone you loved, then the answer is always going to be yes. And so, you should always err on the side of sharing.

Dr. Richard Owings:

I totally agree with it.

Dr. Juanita Evans:

I think you've summarized it perfectly.

Dr. Richard Owings:

Yeah. It's all about patient care and so you just have to do it. Actually, once I brought it to them, their response was usually, "Oh, thank you for bringing this up. Why don't we order another stain? Why don't we go ahead and send this out so we're all comfortable?" It ended up not being a big deal.

But I think as pathologists, we went into a field where we avoid conflict and disagreement is a potential point of conflict. So, I think that's the important thing to emphasize is, do you want the best for patient outcome and it's about the patient. And so, you just have to bring it forward. And if they get mad, they get mad. But in most cases it's not a politically charged thing or people don't typically get angry about it.

It's just part of your job. All right. Well you guys, this has been a great discussion. Is there anything else you guys want to discuss or you have final closing comments?

Dr. Juanita Evans:

I guess I'll throw it out there. I think what I like so much with talking with you guys for the last 45 minutes or so is how differently all of our practice have approached taking care of errors before they start and how to take care of them after they start. So, I think it's a lot of really good ideas. And personally I've liked to talk to my group about what we might could do a little bit differently to have maybe a little bit better of a quality management plan when it comes to errors and anatomic pathology. So, I love the ideas, guys. Thanks.

Dr. Yasmeen Butt:

Yeah, thank you. I really enjoyed talking to you guys and definitely learned a bit about how the different groups approach things. And I'll just say in closing that, as I mentioned before, mistakes happen and it's uncomfortable and it's unfortunate, but to do your best to stop the mistakes from happening. And if they do happen to try to make the most out of them, disclose immediately to the clinician so they can reach out to the patient and then share it with your colleagues. Don't look at it as a shameful thing.

Look at it as a learning opportunity. That's the best way to approach these things.

Dr. Richard Owings:

Yep. And just keep getting better. Basically, that's the whole point of quality management. You just identify errors and eliminate them in the future and keep improving. All right. Well, that was great you guys. Thank you.

Dr. Juanita Evans:

Yeah. Oh, let me just throw up there real quick. On the cap.org website, there's a lot of materials from the New in Practice Committee with a lot of personal experience from new in practice pathologists that may also give you some good ideas about what to do for error management, error reduction, and then dealing with the stress of actually going through one. So, check that out.

Dr. Richard Owings:

Yeah. Thanks, Juanita. And that's the New in Practice Committee page on the College of American Pathologists.

Dr. Juanita Evans:

Thanks.

Dr. Richard Owings:

All right. Thank you, guys.

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