TY - JOUR
AU - Raab, Stephen S.
AB - CASE REVIEW Histology Errors Use of Real-Time Root Cause Analysis to Improve Practice Jennifer L. Condel, BS, SCT(ASCP)MT,* Drazen M. Jukic, MD, PhD,* David T. Sharbaugh,§ and Stephen S. Raab, MD*†‡ tissue discrepancy. The histotechnologist retrieved the slide Abstract: Anatomic pathology errors can occur at any of the stages tray containing the skin cases being questioned. Each case through which a specimen passes, from transport, through the gross had been physically separated from the other by leaving blank room and histology, and finally through examination, sign-out, and spaces between the cases on the tray. From a visual inspec- report transmission. Most errors are detected by redundant methods tion by the histotechnologists, it was noted the tissue sections of slide review, which often detects interpretive or clinical sampling errors. However, other methods, such as the Toyota Production did not appear the same within each consecutive accession System (TPS) process, may be used to detect and correct errors that number (case A and case B). The histotechnologist proceeded are noninterpretive in nature. We illustrate how the TPS process may to pull all tissue blocks associated with case A and case B and be used to detect and correct errors occurring in 
TI - Histology Errors Use of Real-Time Root Cause Analysis to Improve Practice
JF - Pathology Case Reviews
DO - 10.1097/01.pcr.0000155793.51378.ba
DA - 2005-03-01
UR - https://www.deepdyve.com/lp/wolters-kluwer-health/histology-errors-use-of-real-time-root-cause-analysis-to-improve-XYH5GjXIQB
SP - 82
EP - 87
VL - 10
IS - 2
DP - DeepDyve
ER -