Tuesday, December 27, 2005

ERRORS TO AVOID IN EYE PATHOLOGY

HERE IS A LIST OF ERRORS IN EYE PATHOLOGY THAT ARE ALL TOO COMMON AND A BRIEF EXPLANATION:
1. Specimens suspected of cancer failed to be properly oriented and inked. This is most common in outside cases because the small size of the specimen does not seem to bear credible margins to a general pathologist. A resident on the service should consider it necessary to ink all cases suspected of cancer unless otherwise determined by the attending pathologist.
2. Inadequate cleaning of the forceps between cases. It is possible to carry over tumor cells from one case to the next. Although this is generally obvious when the case is reviewed, it is much safer to prevent this by washing the forceps between cases. This is generally necessary to also remove the marking inks. At the end of each day the forceps and bench are cleaned with bleach.
3. Unfixed specimens are ruined because of a delay in fixation. This occurs most frequently when a specimen arrives without fixation as is frequently the case with vitreous aspirations and ocutome washings. The resident should recognize that the specimen does not have a formalin label on it and proceed with processing or ask for assistance from the attending pathologist.
4. Errors in reporting are too common and should be avoided. Here are the most common:
a. The patient's name is spelled incorrectly and another patient is assigned to the case. This occurs because the computer gives you accession choices from thousands of cases. This can be avoided by checking the date of birth and other identifying information carefully.
b. Erroneous or inadequate history may lead to a misdiagnosis. The resident must carefully verify the historical information and make sure it is complete before attempting to make a diagnosis.
c. Failure to record for the permanent record the orientation, or marking inks used. Since the computer generated report is will be the final permanent record, it is critical for the resident to accurately describe the orientation, plane of section and marking inks so that the slides can be interpreted years later by another.
d. In cases with multiple specimens, failure to describe the anatomic location of the specimens and refer to the specimen in this way throughout the report. This makes the report difficult for the surgeon to follow. Using the cassette letter to refer to the case is not acceptable since these letters do not necessarily corresponding to the specimen number ( if it does it is simply coincidence).
e. Typographical errors both of omission and commission. Please check your work so this does not happen.
f. The wrong date is recorded for specimen receipt. This occurs because the computer is programmed to default to the day before your date of accession for all specimens you are accessioning and examining. Obviously this is erroneous since you are generally examining the day of surgery for Jules Stein cases and often several days later for outside cases. Please be vigilant about recording the correct date for the surgical procedure that generated the specimen (also called the date of service), or alternatively the day the specimen arrived in our laboratory as the receipt date.

5. Errors in Gross examination. These generally occur because the resident attempts to gross the specimen without seeking the advice of the attending pathologist. Please remember that there is no rush to gross in specimens as they are processed once per day. Adequate supervision is available to answer any questions, the resident simply needs to inform the attending pathologist as to the existence of the specimen. Under no circumstances should the resident attempt to gross in a specimen in which they have not been properly instructed and trained.



6. Leaving portions of the report blank because you do not know the answer. Every single case is examined and signed out by the attending pathologist. In our system it is important that you attempt to make an effort to come to a diagnosis. This is key to the educational experience provided. The attending pathologist will correct erroneous diagnoses and go over errors with you. Nothing ventured, nothing gained!

7. Outside slides are not labeled in pencil with the UCLA surgical number. Labeling the slide with our number is critical as the slides and paperwork may be separated and in order to return the slides they must be referenced. As a double check we put the outside surgical number in our log book and as further insurance each report contains the exact labeling of the slide (see outside slide reports).

8. Failure to record the final surgical diagnosis in the log book. The resident is responsible for keeping this record as it serves an educational purpose. In cases in which the attending does not choose to review with the resident, the act of recording the diagnosis will provide positive reinforcement for the correct diagnosis or call attention to questions on a case that the residents may wish to ask on the attending pathologist. It also allows the resident to see the final wording of the case. In addition it provides an instant record from which to refer to inform the clinicians regarding unsuspected diagnoses.

9. Failure to order special tests on computer from the histology lab. It is critical that the resident both record their order on a paper copy as well as order the test on the computer. The computer record is received by the histology lab and they will do the special stains or deeper sections in the wee hours of the morning. The computer provides a record if for some reason there is a problem with the paperwork...(e.g. lost in transition by couriers).

10. Failure to record a case in the log book. Every single case must be logged in by hand to the specimen accession log book. This is necessary in case of computer crashes, is an integral part of resident education and is critical for medicolegal considerations.

11. Failure to write on cassette in Pencil! Ink is soluble in alcohol and organic solvents and washes right away. All of the labels on the cassettes may vanish and a disaster may ensue. It is critical to label cassettes in PENCIL and write clearly. Put the name of the patient on the side of the cassette.

11. Failure to turn off the microscope at the end of the day. The pointer light and microscope light should be turned off at the end each day.

12. Failure to check packages from outside consultations for blocks, paper work or additional slides. Remember the packages are kept until the case has been completely signed out by the attending pathologist.

13. Failure to use biopsy bags for small specimens may result in lost specimens.

14. Failure to fold the edges of the biopsy bag may result in lost specimens.

15. Failure to wet the embedding bag to retain its fold may result in lost specimens. The combination of 14 and 15 increases the likelihood of losing the specimens.





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