Case report: Successful simultaneous heart-kidney transplantation across a positive complement-dependent cytotoxic crossmatch.

Preformed donor-specific antibodies are associated with a higher risk of rejection and worse graft survival in organ transplantation. However, in heart transplantation, the risk and benefit balance between high mortality on the waiting list and graft survival may allow the acceptance of higher immunologic risk donors in broadly sensitized recipients. Transplanting donor-recipient pairs with a positive complement dependent cytotoxic (CDC) crossmatch carries the highest risk of hyperacute rejection and immediate graft loss and is usually avoided in kidney transplantation.

The next phase in patient safety education: Towards a standardized, tools-based pathology patient safety curriculum: ' .

Patient safety education is a mandated Common Program Requirement of the Accreditation Council for Graduate Medical Education and for the Royal College of Physicians and Surgeons of Canada in all medical residency and fellowship programs. Although many hospitals and healthcare environments have general patient safety education tools for trainees, few to none focus on the unique training milieu of pathologists, including a mix of highly automated and manual error-prone processes, frequent multiplicity of events, and lack of direct patient relationships for error disclosure. We established a national Association of Pathology Chairs-Program Directors Section Workgroup focused on patient safety education for pathology trainees entitled Training Residents in Patient Safety (TRIPS).

Erroneous Patient Tissue Contaminants in 1574 Surgical Pathology Slides: Impact on Diagnostic Error and a Novel Framework for Floater Management.

Context.—: Tissue contaminants on histology slides represent a serious risk of diagnostic error. Despite their pervasive presence, published peer-reviewed criteria defining contaminants are lacking.

Pathology trainees rarely report safety incidents: A review of 13,722 safety reports and a call to action.

Reporting and understanding patient safety incidents is a cornerstone of improving patient care quality and safety. The Accreditation Council for Graduate Medical Education specifically mandates that physician trainee education include participation in the recognition, reporting, and root cause analysis of patient safety incidents. Studies on safety event reporting, however, have consistently shown that attending physicians submit few safety reports, and trainees submit even fewer.

Prioritizing Patient Safety and Minimizing Waste: Institutional Review of Cases and a Proposed Process for Designing a Surgical Pathology Gross-Only Examination Policy.

Objectives: Gross-only examination policies vary widely across pathology departments. Several studies-particularly a College of American Pathologists' Q-Probes study-have looked at the variations in gross-only policies, and even more studies have addressed the (in)appropriateness of certain specimen types for gross-only examination. Few, if any, studies have tackled the important task of how to revise and safely implement a new gross-only examination protocol, especially in collaboration with clinical colleagues.

Patient-facing communication for cytopathologists: A framework for disclosing diagnostic error.

Medical errors are a major source of harm to patients. Regulatory bodies mandate and patient safety experts advocate the disclosure of medical errors to patients to promote transparency and to create accountability for improving health care processes. Although pathologists regularly report errors-either to pathology or clinical colleagues or via internal safety reporting systems-few pathologists directly disclose those errors to patients.

The value of monitoring amended reports in cytopathology quality programs: A biennial review.

Background: Quality and safety are the foundation of the practice of cytopathology. Review of key performance indicator (KPI) data can shine a light on laboratory vulnerabilities and potential areas for targeted improvement. The rate and content of amendment reports is a frequently monitored KPI in anatomic pathology, but few have studied its value in cytopathology.

All in for patient safety: a team approach to quality improvement in our laboratories.

Patient safety and quality improvement initiatives are integral parts of every cytopathology laboratory. The need to revisit our approaches to patient safety are essential in light of the expanding test menu, ancillary studies, comprehensive diagnostic reports, and emergence of new technologies for augmenting cytologic diagnosis. Our interview with Drs.

Something's Lost and Something's Gained: Seeing Reference Laboratory Quality from Both Sides, Now.

Growing regulatory burdens, payment model changes, and increased complexity in laboratory medicine have contributed to an increased reliance on reference laboratories. Although reference laboratories often offer rapid, low cost, high quality testing, outsourcing laboratory tests can create quality and patient safety vulnerabilities particularly in the pre-analytic and post-analytic phases of the test cycle. Disconnects in governance, policy, and information technology between the reference laboratory and the referring provider conspire to increase risk.

Frozen-Section Checklist Implementation Improves Quality and Patient Safety.

Objectives: An intraoperative consultation (IOC) checklist was developed and implemented aimed at standardizing slide labeling and monitoring metrics central to quality and safety in surgical pathology.

Design: Data were collected for all IOC cases over a 9-month period. Slide labeling defect rates and IOC turnaround time (TAT) were recorded and compared for the pre- and postimplementation periods.

Pre-analytic error: A significant patient safety risk.

Ancillary testing in cytopathology has grown dramatically over the past decade, enhancing the clinical value of cytology specimens obtained via minimally invasive methods. However, a complex testing landscape brings with it new and emerging risks to patient safety. Recognition of complicated systems issues as well as shared responsibility in process ownership can help to minimize safety risks.

Disclosure of Harmful Medical Error to Patients: A Review With Recommendations for Pathologists.

Harmful error is an infrequent but serious challenge in the pathology laboratory. Regulatory bodies and advocacy groups have mandated and encouraged disclosure of error to patients. Many pathologists are interested in participating in disclosure of harmful error but are ill-equipped to do so.

Achieving High Reliability in Histology: An Improvement Series to Reduce Errors.

Objectives: Despite sweeping medical advances in other fields, histology processes have by and large remained constant over the past 175 years. Patient label identification errors are a known liability in the laboratory and can be devastating, resulting in incorrect diagnoses and inappropriate treatment. The objective of this study was to identify vulnerable steps in the histology workflow and reduce the frequency of labeling errors (LEs).