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    Pathology plays an important role in patient safety by providing accurate and timely diagnoses to guide treatment. Potential errors in pathology can occur during the pre-analytic, analytic and post-analytic phases. It is important to identify common errors and put procedures in place to prevent them, such as standardized processes, automation, and quality control measures. Ensuring qualified pathologists and good laboratory management through accreditation also helps improve performance and reduce errors. The goal is to establish a culture of safety and continuous improvement in pathology practices.

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    Pathology plays an important role in patient safety by providing accurate and timely diagnoses to guide treatment. Potential errors in pathology can occur during the pre-analytic, analytic and post-analytic phases. It is important to identify common errors and put procedures in place to prevent them, such as standardized processes, automation, and quality control measures. Ensuring qualified pathologists and good laboratory management through accreditation also helps improve performance and reduce errors. The goal is to establish a culture of safety and continuous improvement in pathology practices.

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    13 views21 pages

    The Role of Pathology in Patient Safety F

    Uploaded by

    achmad rizki
    Pathology plays an important role in patient safety by providing accurate and timely diagnoses to guide treatment. Potential errors in pathology can occur during the pre-analytic, analytic and post-analytic phases. It is important to identify common errors and put procedures in place to prevent them, such as standardized processes, automation, and quality control measures. Ensuring qualified pathologists and good laboratory management through accreditation also helps improve performance and reduce errors. The goal is to establish a culture of safety and continuous improvement in pathology practices.

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    of 21

    THE ROLE OF PATHOLOGY

    IN
    PATIENT SAFETY

    Endang SR Hardjolukito
    BPMPPI-IAPI
    Definition
    •  IOM :
    – Patient safety was defined by the IOM as “the
    prevention of harm to patients.”
    Emphasis is placed on the system of care delivery
    that :
    (1) prevents errors
    (2) learns from the errors that do occur
    (3) built on a culture of safety that involves health
    care professionals, organizations, and patients.

     Patient safety: achieving a new standard for care. Washington, DC: National Academies Press; 2004 .
    The role of pathology

    DIAGNOSIS
    Gold standard TREATMENT

    ACCURATE
    TIMELY PATIENT SAFETY
    COMPLETE

    Good laboratory Qualified pathologist


    The role of pathology

    Patient
    Error safety

    1. What is potential / common error in AP ?


    identification in 3 steps cycle : pre-analytic and post

    2. How to prevent error in AP?


    tools to measure error
    IDENTIFICATION OF ERROR

    Vignettes in Patient Safety - Volume 3, 2018


    http://dx.doi.org/10.5772/intechopen.79634
    IDENTIFICATION OF ERROR

    IAPLPS ( Initiative of Anatomic Pathology Laboratory for Patient


    Safety) : 47 spot for potential risk in PS : 26 are high risk

    Lab Medicine 2017;48;195–201 www.labmedicine.com


    196 DOI: 10.1093/labmed/lmw068
    Identification of error

    Arch Pathol Lab Med—Vol 132, February 2008


    How to prevent error ?

    1. Standardize all procedures


    - pre-analitic-post
    - ensure right things done
    2. Remove all distraction
    3. Introduce automation
    4. Take away any inconsistent tool.

    Arch Pathol Lab Med—Vol 132, February 2008


    How to prevent error ?

    Develop tool to
    Common error Provide instruction
    measure
    identification manual / SOPs & QC
    performance
    • Patient-specimen • Manual to match • Zero mismatch
    ID mismatch the patient ID event
    • Inadequate IHC • Validated staining • <5% repeat
    staining protocol and staining
    assess staining
    quality
    The role of pathology

    DIAGNOSIS
    Gold standard TREATMENT

    ACCURATE
    TIMELY PATIENT SAFETY
    COMPLETE

    Good laboratory Qualified pathologist


    How to measure the Lab.’s n Pathologist’s
    performance ?
    • Good laboratory :
    – Good management system
    – Good quality of lab. product
    • EQA / proficiency test
    • Qualified pathologist :
    – Audit Discrepancy in diagnosis
    • FS –histology & cytology-histology correlation
    • Intra / interdepartmental
    • Review
    Arch Pathol Lab Med—Vol 129, April 2005
    Arch Pathol Lab Med—Vol 129, April 2005
    Arch Pathol Lab Med—Vol 129, April 2005
    How to get a good performance

    Supportive environment

    A robust system
    Lab. management system
    Standardized technique protocol
    Quality management system

    ACCREDITATION
    Same standards as ISO/KAN & KALK

    • Management standards ( Staff qualification,


    lab safety program, TAT policy , reagens
    availability & selection policy , licensed &
    accredited ref lab, monitoring ref lab service )
    • Technical standards (well maintained
    equipment, norm and ranges, technical SOPs
    QC, proficiency test)
    Regulation on patient safety
    PMK no 11 th 2017

    Hospital-based Stand-alone
    Revise regulation is
    Pathology lab. being prepared by MOH
    Pathology lab.

    PATIENT SAFETY
    PATIENT SAFETY
    Summary
    • As Pathology diagnosis is the basis for patient
    management, Pathology has important role in
    patient safety
    • Error reduction in pre – analytic and post
    analytic : identification of potential error &
    error prevention
    • Good laboratory & qualified pathologist
    • Accreditation
    Thank you
    Thank you

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