Analysis of Near-Miss Events and Errors in Handling Thyroid Specimens; A Gross Room Experience from a Pathology Lab

Abstract

Background and Objective: Thyroid specimens constitute a major bulk of the head and neck surgical specimens received at the Pathology Departments. Careful handling of the specimens in the grossing room will result in an efficient reporting of useful histological parameters required for patient management and prognosis. The objective of this study was to analyze different errors and near-miss events in the grossing of thyroid specimens in the surgical pathology gross room of a Tertiary Care Hospital in Lahore, Pakistan.

Methods: A cross-sectional analysis was done on different thyroid specimens received at the Pathology reception of Lahore General Hospital, Lahore, Pakistan, from January 2022 to April 2023. Different types of errors involved in standard gross examinations were studied. Data were entered using SPSS version 23.0.

Results: Errors observed in the preanalytical phase included the use of inappropriate fixative (15.2%), insufficient clinical information (76.5), mislabeled jar/request form (7.6%), and loss of specimen (8%). Grossing errors included insufficient grossing notes (12.2%), cutting thick slices (10.7%), missing lesions on gross examination (9.9%), inappropriate inking (6.9%), overfilling cassette with large tissue sections (6.9%), mislabeled cassettes (93.8%), and incomplete submission of capsule (2.3%).

Conclusion: This study concludes that errors and near-miss events in handling thyroid specimens can be avoided by effective training of the handling staff and grossing residents. Collaboration between clinical wards and histopathology laboratories can also be helpful in this regard.