Pathology Patterns Reviews最新文献

{"title":"Patient Safety Partnership Projects in the Clinical Laboratory","authors":"E. Wagar, Merian Raz, B. Yasin","doi":"10.1309/620L63B6BV9CG6K1","DOIUrl":"https://doi.org/10.1309/620L63B6BV9CG6K1","url":null,"abstract":"","PeriodicalId":250671,"journal":{"name":"Pathology Patterns Reviews","volume":"1 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2006-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"114359651","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"The Agency for Healthcare Research and Quality Hospital Labs Studying Patient Safety Consortium and Error Reduction","authors":"S. Raab, D. Grzybicki, J. Janosky, R. Zarbo, K. Geisinger, F. Meier, C. Jensen, Eva M. Wojcik, M. Haber, S. Geyer","doi":"10.1309/7GWUCGFLYG2VFHJ1","DOIUrl":"https://doi.org/10.1309/7GWUCGFLYG2VFHJ1","url":null,"abstract":"Definition of Anatomic Pathology Testing Error Patient safety researchers and practitioners are not agreed on the definition of medical error.22,23 The IOM definition is that a medical error is the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim.3 Some have argued that this definition of error is too broad and classifies events as errors when in fact they may have occurred naturally in the course of normal medical care. For example, patient safety researchers disagree on the classification of a patient death immediately attributable to The Agency for Healthcare Research and Quality Hospital Labs Studying Patient Safety Consortium and Error Reduction Stephen S. Raab, MD,1 Dana M. Grzybicki, MD, PhD,1 Janine E. Janosky, PhD,2 Richard J. Zarbo, MD, DMD,3 Kim R. Geisinger, MD,4 Frederick A. Meier, MD,3 Chris Jensen, MD,5 Eva M. Wojcik, MD,6 Marian Haber, MD,7 and Stanley J. Geyer, MD8*","PeriodicalId":250671,"journal":{"name":"Pathology Patterns Reviews","volume":"21 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2006-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"125843777","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Clinical Applications of Flow Cytometry for Nonneoplastic Disorders","authors":"Z. Kaleem","doi":"10.1309/DU1VUKDPK7FBEH1G","DOIUrl":"https://doi.org/10.1309/DU1VUKDPK7FBEH1G","url":null,"abstract":"","PeriodicalId":250671,"journal":{"name":"Pathology Patterns Reviews","volume":"1 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2006-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"127302697","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Measuring Health Care Performance Identification and Standardization of Laboratory Quality Indicators","authors":"D. Grzybicki, S. Raab","doi":"10.1309/A68D7YJB2LMLBPJJ","DOIUrl":"https://doi.org/10.1309/A68D7YJB2LMLBPJJ","url":null,"abstract":"","PeriodicalId":250671,"journal":{"name":"Pathology Patterns Reviews","volume":"105 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2006-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"115853884","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Deleterious Clinical Effects of Allogeneic Blood Transfusion–Related Immunomodulation","authors":"E. Vamvakas","doi":"10.1309/9B7RWAYVVLCL58WW","DOIUrl":"https://doi.org/10.1309/9B7RWAYVVLCL58WW","url":null,"abstract":"The debate about the existence of deleterious clinical effects of allogeneic blood transfusion (ABT)-related immunomodulation (TRIM) continues and is now concentrated on differing interpretations of findings of randomized controlled trials (RCTs). This review focuses on the results of studies reported during the last 5 years, especially recent RCTs, studies of the association of ABT with all-cause mortality, studies of the hypothesis attributing TRIM effects to WBC-derived soluble mediators that accumulate during storage, and studies comparing the risk of adverse outcomes before and after the implementation of WBC reduction of cellular blood components. When this literature is considered along with that available before 2001, the results from studies of adverse clinical TRIM effects remain contradictory. Based on the totality of the evidence, there seems to be an association between WBC-containing ABT and short-term (≤3 months posttransfusion) mortality that becomes manifest in cardiac surgery and in comparison with administration of allogeneic blood components filtered before storage. However, with the possible exception of cardiac surgery, there is no area in the extensive TRIM literature in which there is agreement among the studies or in which the observed clinical effects follow consistently from a postulated biologic mechanism. Allogeneic blood transfusion (ABT) results in the infusion into the recipient of large amounts of foreign antigens in soluble and cell-associated forms. The persistence of these antigens in the circulation of the recipient may create conditions that allow for the development of immune down-regulation. Evidence from a variety of sources indicates that ABT enhances the survival of renal allografts 1 and may increase the recurrence rate of resected malignant neoplasms 2 and the incidence of postoperative bacterial infections, 3-8 as well as reduce the recurrence rate of Crohn disease 9 and/or activate infections with cytomegalovirus or HIV. 10 This syndrome, the mechanisms and clinical relevance of which remain to be defined, has been referred to in the transfusion medicine literature as ABT-related immunomodulation (TRIM). 11,12","PeriodicalId":250671,"journal":{"name":"Pathology Patterns Reviews","volume":"1 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2006-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"121059560","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Reducing Errors in the Practices of Pathology and Laboratory MedicineAn Industrial Approach","authors":"D. Novis, George Konstantakos","doi":"10.1309/MYJEA036EDQQEH4X","DOIUrl":"https://doi.org/10.1309/MYJEA036EDQQEH4X","url":null,"abstract":"The use of quality benchmarking and performance tracking techniques has been successful in reducing errors in the practices of pathology and laboratory medicine. However, techniques developed in the manufacturing industry, specifically those pioneered by Toyota Motor have been more efficient and effective in reducing errors than those developed in the health care industry. We discuss some of those techniques and draw analogies as to how they might be applied in the laboratory. Traditional Approach to Error Reduction: Benchmarking and Best Practices For more than a decade and a half, the College of American Pathologists (CAP) has defined the nature of quality in the practices of laboratory medicine and anatomic pathology through its quality benchmarking Q-Probes program. By using these data collection tools, voluntary participants representing heterogeneous groups of hospitals and practice environments located in all geographic regions of the United States have measured standard parameters of quality. In each of these studies, enormous amounts of data were collected during periods lasting weeks to months. From these data, CAP statisticians have established benchmarks of laboratory performance. Participants have been able to gauge their performances relative to those of the national benchmarks determined in these studies and those of their peers participating in the studies. In each study, participants also have provided general information describing how laboratory services are provided in their institutions. CAP statisticians have used these data to determine which laboratory and professional practices are associated with superior outcomes.1-5 For example, 2 Q-Probes studies examined the frequencies of the following: (1) completion of 4 standard components of patient and blood unit identification before performing blood transfusions and (2) performance of required vital sign monitoring during the transfusions.6 Participants representing a total of 600 hospitals audited 16,494 transfusions. The median frequencies with which health care workers performed all patient identification and monitoring procedures ranged from 10.0% to 69.0% and 90.2% to 95.0%, respectively, in both studies. Individual practices and/or institutional policies associated with greater Reducing Errors in the Practices of Pathology and Laboratory Medicine An Industrial Approach David A. Novis, MD,1,2 and George Konstantakos3","PeriodicalId":250671,"journal":{"name":"Pathology Patterns Reviews","volume":"72 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2006-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"129178372","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Transforming to a Quality Culture","authors":"R. Zarbo, R. D'angelo","doi":"10.1309/KVT7NWVPJR73T4K6","DOIUrl":"https://doi.org/10.1309/KVT7NWVPJR73T4K6","url":null,"abstract":"We describe the cultural transformation of the surgical pathology laboratory at Henry Ford Hospital, Detroit, MI, to one that has adopted an expectation for empowered workers to see their daily work in the context of continually learning and making effective process improvements that are designed and tested by the scientific method. This transformation has been achieved by creating an organizational and educational framework for implementing guiding principles originally systematized as the basis of lean manufacturing by our founder, Henry Ford, at the turn of the century, and incorporating the innovations of the Toyota Production System. We present novel data collection techniques to establish baseline states by which to gauge the success of changes and lessons from rapid process improvement studies. Herein, we share our experiences, lessons learned, and successes to date in the pathology-based Henry Ford Production System. We do not make changes for the sake of making them, but we never fail to make a change once it is demonstrated that the new way is better than the old way. We hold it our duty to permit nothing to stand in the way of progress. —Henry Ford 1","PeriodicalId":250671,"journal":{"name":"Pathology Patterns Reviews","volume":"1199 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2006-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"116067433","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"The Use of Decision Analysis for Understanding the Impact of Diagnostic Testing Errors in Pathology","authors":"M. Roberts","doi":"10.1309/DML7PAKWH7LUL39C","DOIUrl":"https://doi.org/10.1309/DML7PAKWH7LUL39C","url":null,"abstract":"","PeriodicalId":250671,"journal":{"name":"Pathology Patterns Reviews","volume":"62 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2006-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"126272584","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"The physician and the laboratory: Partners in reducing diagnostic error related to laboratory testing:","authors":"M. Graber","doi":"10.1309/54XR770U8WTEGG1H","DOIUrl":"https://doi.org/10.1309/54XR770U8WTEGG1H","url":null,"abstract":"","PeriodicalId":250671,"journal":{"name":"Pathology Patterns Reviews","volume":"174 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2006-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"122816246","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"The Second Annual Improving Hospital and Laboratory Safety MeetingDiscussion Session Proceedings","authors":"D. Grzybicki, T. Merryman, D. Sharbaugh, S. Raab","doi":"10.1309/6NU5LL8HU3C7LERL","DOIUrl":"https://doi.org/10.1309/6NU5LL8HU3C7LERL","url":null,"abstract":"","PeriodicalId":250671,"journal":{"name":"Pathology Patterns Reviews","volume":"25 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2006-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"131284199","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}