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National Summit on Medical Errors and Patient Safety Research
American Society of Clinical PathologistsThe first National Summit on Medical Errors and Patient Safety Research was held on September 11, 2000, in Washington, DC. Sponsored by the Quality Interagency Coordination Task Force (QuIC), the Summit’s goal was to review the information needs of individuals involved in reducing medical errors and improving patient safety. More importantly, the summit set a coordinated and usable research agenda for the future to answer these identified needs. Selected applicants testified at the summit as members of the witness panels. The remainder of the applicants were invited to submit written comments for consideration by the steering committee. One of these statements follows. Disclaimer and Copyright Statements Thank you for the opportunity to submit this statement to the National Summit on Medical Errors and Patient Safety Research. The American Society of Clinical Pathologists (ASCP) is a nonprofit medical specialty society organized for educational and scientific purposes. Its 75,000 members include board certified pathologists, other physicians, clinical scientists and certified medical technologists and technicians. The purpose of the ASCP is to improve public health by advancing the science and practice of pathology and laboratory medicine. Patient safety is an important part of this principle. To continue its leadership role in advancing patient safety, ASCP has developed a Patient Safety Initiative. This statement will focus, in part, on this initiative and how it impacts various disciplines within and outside the laboratory. As you requested, this statement will also address methods of communication that will assist in better dissemination of patient safety information. For purposes of your research agenda, we wish to focus on three areas of further study: (1) further analysis of how a second opinion may improve patient safety; (2) correlation between autopsy rates and reducible errors; and (3) effectiveness of using laboratory data in the management of errors and outcomes of care. Second Opinions ASCP sponsored a "Consensus Conference on Second Opinions in Diagnostic Anatomic Pathology: Who, What and When" on June 21, 2000, in Washington, DC. The public conference convened eight pathology experts of various disciplines, a surgeon, and a patient representative to develop a consensus on what specimens should be reviewed under second opinions, whose opinion prevails upon a second review, when a second opinion should occur, and to develop general guidelines for second opinions in diagnostic anatomic pathology. The consensus document was published in the September 2000, edition of the American Journal of Clinical Pathology. A copy is attached for your information. Overall, the conference determined that second opinion is an important component of total quality assurance programs in diagnostic surgical pathology and cytopathology, and is a key aspect in the assurance of patient safety for tissue and cytology-based diagnoses. Codified strategies for second opinions should be employed based on result criticality, existing medical knowledge, statutory regulations, individual departmental experience, individual pathologist experience, and clinical information. The consensus panel described specifically when second opinion on internal materials is warranted, and when extra-departmental consultations should be considered. While the conferees challenged that "pathology societies should initiate educational program to inform clinicians and patients regarding the value of second opinion, the turn around time delays which second opinions will produce, and the legitimate differences of opinion that can exist in difficult cases," the group also encouraged funding agencies to support research into the detailed analysis of second opinion as a patient safety mechanism. ASCP believes this is an important role that may be assumed by the Agency for Healthcare Research and Quality. Correlation Between Autopsy Rates and Reducible Errors ASCP encourages the use of the autopsy for the quality assurance of medical diagnostics and services. The autopsy is an important component in the assessment of the quality of care. For example, a study published in the August 1998 issue of the American Journal of Clinical Pathology found that of 176 autopsies examined in a major tertiary care transplantation referral center, 79 autopsies, or 44.9%, revealed one or more undiagnosed causes of death. There were 123 undiagnosed causes of death in the 79 cases. Of the 123 undiagnosed causes of death, 13 were sole immediate causes of death, 72 were one of multiple immediate causes, 22 were intervening causes, and 16 were underlying causes of death. A retrospective study published this year in Mayo Clinic Proceedings (John Rosen, et. al. 2000; 75:562-567) compared clinical diagnoses and postmortem major diagnoses of 100 patients, and concluded that, in 16 percent of the cases, autopsy findings revealed a major diagnosis that, if known before death, might have led to a change in therapy and prolonged survival. Autopsies frequently discover diagnoses that go undetected by modern high-technology medicine. Through the autopsy, problems in diagnosis may be recognized and ultimately assist in finding solutions to similar medical problems in future patients. Research has consistently demonstrated that the autopsy is the best source of information on diagnostic accuracy, "the ultimate audit" (Arch Pathol Lab Med. 1984; 108:444-445) for ensuring high-quality medical care, and a valuable tool for evaluating therapy, tracking diseases, educating health professionals, and measuring how health care systems may be improving patient care. A review of literature published in the last two decades found a discrepancy rate between clinical and post-mortem diagnoses of approximately fifty percent. Recommendations on how to increase the autopsy rate include providing autopsy feedback guidelines for physicians talking to families of deceased patients and increasing the emphasis in medical education on the benefits of the autopsy. The ASCP firmly believes that the autopsy significantly contributes to monitoring clinical judgment in the medical community. For quality assurance purposes alone, the autopsy is a critical service. Any condition of participation addressing the autopsy should also assure appropriate compensation for this service. Use of Laboratory Data Clinical information, obtained from the laboratory, can assist in building a safer health system. Measures may be developed to use objective clinical data to review medical cases and better communicate appropriate health outcomes. ASCP is working with other organizations representing the laboratory, through the Laboratory Healthcare Partnership, in encouraging outcomes research and the appropriate utilization of laboratory tests. The Partnership is funding a study to demonstrate the cost-effectiveness of using laboratory data in the management of risk, cost and outcomes of medical care. Laboratory data may be used to manage better patient outcomes in a number of healthcare settings. Laboratory medicine results can be integrated with existing, new and emerging clinical systems to improve patient care. For example, in clinical chemistry, algorithms have been developed that will flag or indicate when patients are in high risk situations, which then permits clinical intervention before an adverse event occurs. As another example, laboratory professionals perform therapeutic drug monitoring, which can effectively reduce toxicity in patients on a drug regimen. The use of this data should be considered as the National Summit deliberates on the enhancement of the existing knowledge in the area of patient safety. Communication There are several vehicles available for disseminating pertinent information to the pathology and laboratory medicine community. As an educational organization, ASCP has available the use of teleconferences, national and regional meeting platforms, monthly magazine, peer-reviewed clinical journal, website, specialty-specific listserves, and a variety of newsletters. Overall Pathology and laboratory medicine have developed and continue to support the use of quality processes for the systematic detection and prevention of errors. These efforts concentrate on building safety into the delivery of health care. ASCP looks forward to working with you on future patient safety efforts. If you have questions or require additional information, please contact Robin Stombler, Director of the ASCP Washington Office, at (202) 347-4450. Current as of September 2000 Internet Citation: American Society of Clinical Pathologists. Additional Statement. National Summit on Medical Errors and Patient Safety Research. September 2000. http://www.quic.gov/summit/aascp.htm Return to Additional Statement Directory |