A New Approach to Error

Patient Safety Awareness Week 2020 runs March 8^th to 14^th – and no one is more aware of patient safety concerns than the laboratory that handles their testing. To find out more about patient safety in the lab, we spoke to Matt Clarke, Chair of the Royal College of Pathologists’ Trainees’ Advisory Committee and a Clinical Fellow in Histopathology, about his work.

“Patient safety is fundamentally important across the whole of medicine, and crucially in pathology,” Clarke declares. “That’s because we’re always striving to make an accurate diagnosis for a patient from the very start and, if we’re not able to achieve that, the patient heads toward the wrong diagnosis, and therefore the wrong treatment and management pathway.” He also warns that errors can happen anywhere at any time – including with consultants, trainees, scientists, and administrative staff – and that vigilance is, therefore, vital. “It’s our role to ensure that mistakes are not hidden away, because if everyone is aware of the types of errors that have occurred, we can work out how to prevent them in the future. Mistakes are an inevitable part of human nature. It is not helpful to find someone to blame. Our role is to try to understand how the error happened, learn from it, and minimize the chances of it happening again.”

Clarke’s current work, which is mainly research-based, also has an important role in patient safety. Here, patient safety comes under the broader heading of clinical governance – a systematic approach to maintaining and improving the quality of patient care. Research forms a crucial aspect of clinical governance by helping to improve and change practice using an evidence-based approach.

There are also important practical aspects that need to be considered when helping to maintain patient safety in a pathology lab, such as checking specimens and samples when they arrive and ensuring that name tags correspond to the correct clinical details. Another example of a potential threat to patient safety is ‘carry-over’, which can be observed using the microscope. It occurs when small pieces of tissue from other cases end up on the wrong slide – a phenomenon that most histopathologists will encounter at some point.

“I recall reviewing a slide of a biopsy specimen; it showed a tiny piece of tissue next to a group of cells that appeared malignant. It was only after reviewing the case with a consultant and performing immunohistochemistry that we realized the malignant-looking cells were from a completely different tissue. Because we were able to spot it, there wasn’t any impact for the patient – but the danger of misreporting a benign case as malignant is clear. It’s crucial to remain aware of carry-over and question anything that doesn’t fit with what’s expected.”

Clarke and the Royal College of Pathologists have been working on a project that encourages those who work in pathology to talk about mistakes they may have witnessed or been involved with. “In medicine, we’re always shy when talking about errors. We need to move away from trying to attach blame to a mistake. Mistakes can and will happen to everyone at some point in their career – but the important thing is that we need to be honest and discuss them to prevent them from occurring again.”

In the new scheme, trainees from different pathology specialties sit down together and discuss examples of errors they’ve encountered. The goal? To publish the most important learning points so that trainees across the network have access to the information and can prevent similar mistakes in their own departments. Clarke believes there needs to be a culture change around the approach to error – and fostering much more open discussions, in a safe and non-judgemental environment is key to helping with that.

Laboratorians are always focused and work very hard to provide high quality diagnostic investigations, in both an efficient, timely, and effective way – all of which are important elements of ensuring patient safety. But is there more below the surface? Clarke says, “We need to better promote the work that we do in relation to ensuring patient safety, including the introduction of more open communication channels with all who work in pathology to understand how errors occur and how we can prevent them. We need to be concentrating on this issue and promoting awareness all the time, not just during Patient Safety Awareness Week. It’s relevant to every single day of our careers and something that we continually need to work toward so that we can continue to provide high quality patient diagnostics.”