Abstract：
CONTEXT:Methods to improve surgical pathology patient safety include measuring the frequency of error in specific steps of the surgical pathology testing process, root cause analysis of active and latent components, and implementation of quality improvement initiatives. OBJECTIVE:To determine the frequency and cause of near-miss events in the specimen accessioning, setup, and biopsy-only gross examination testing steps of anatomic pathology. DESIGN:We used an observational checklist method to identify near-miss events. We performed root cause analysis to determine latent factors contributing to near-miss events. We conducted observations for 45 hours during 5 days, involving the accessioning and processing of 335 specimens. RESULTS:We detected a total of 2310 process-dependent and 266 operator-dependent near-miss events, resulting in a near-miss-event frequency of 5.5 per specimen. Root cause analysis showed that all process and operator near-miss events were associated with multiple system latent factors, including lack of standardized protocols, appropriate knowledge transfer, and focus on safety culture. CONCLUSION:We conclude that the increased focus on surgical pathology near-miss events will reveal latent factors that may be targeted for improvement.
journal_name
Arch Pathol Lab Medjournal_title
Archives of pathology & laboratory medicineauthors
Smith ML,Raab SSdoi
10.5858/arpa.2011-0334-OAsubject
Has Abstractpub_date
2011-11-01 00:00:00pages
1436-40issue
11eissn
0003-9985issn
1543-2165journal_volume
135pub_type
杂志文章abstract：:In this article we present a case of an ectopic gestation having morphologic features of a partial hydatidiform mole and demonstrating triploidy by flow cytometry in a patient presenting at 9 weeks' gestation. We include brief comments on partial hydatidiform mole. ...
journal_title：Archives of pathology & laboratory medicine
pub_type： 杂志文章
doi：
更新日期：1993-06-01 00:00:00
abstract：CONTEXT:A Treatise on Pathological Anatomy, published in 1829 by William E. Horner, is the first American textbook on pathology. Several articles have been written on Horner, but they do not evaluate the role that the knowledge he recorded played on the intellectual origin of the discipline of pathology in America. Onl...
journal_title：Archives of pathology & laboratory medicine
pub_type： 传,历史文章,杂志文章
doi：10.5858/arpa.2011-0141-HP
更新日期：2011-12-01 00:00:00
abstract：:We report 2 cases of nonspecific postvaccinial dermatitis following smallpox vaccination. The patients presented with diffuse, pruritic, erythematous macules and papules 11 days (case 1) and 7 days (case 2) following routine smallpox vaccination. Biopsies of the lesions demonstrated spongiotic dermatitis without evide...
journal_title：Archives of pathology & laboratory medicine
pub_type： 杂志文章
doi：10.1043/1543-2165(2004)128<1173:PSDOSV>2.0.CO;2
更新日期：2004-10-01 00:00:00
abstract：CONTEXT:The immunophenotypic profile of basophils is not yet fully established, and the immunophenotypic changes in chronic myelogenous leukemia are not fully characterized. OBJECTIVE:To establish a comprehensive immunophenotypic spectrum of normal basophils and to assess the range of immunophenotypic aberrations of b...
journal_title：Archives of pathology & laboratory medicine
pub_type： 杂志文章
doi：10.1043/1543-2165(2008)132[813:ISOBBM]2.0.CO;2
更新日期：2008-05-01 00:00:00
abstract：CONTEXT:Primary intraosseous squamous cell carcinoma is a rare form of squamous cell carcinoma, arising within the jaws. OBJECTIVE:To clarify the clinicopathologic and behavioral spectrum of primary intraosseous squamous cell carcinoma. DESIGN:The clinical and pathologic findings, treatment, and follow-up data of 39 ...
journal_title：Archives of pathology & laboratory medicine
pub_type： 杂志文章
doi：10.1043/1543-2165-133.11.1834
更新日期：2009-11-01 00:00:00
abstract：:We report an autopsy case of pulmonary hypertension associated with systemic lupus erythematosus in a 48-year-old woman. After 8-year follow-up under a definite diagnosis of systemic lupus erythematosus, she experienced gradually developing exertional dyspnea with palpitation. Her chest x-ray showed clear lung fields ...
journal_title：Archives of pathology & laboratory medicine
pub_type： 杂志文章
doi：
更新日期：1998-05-01 00:00:00
abstract：:Lipoplasty, or liposuction, the surgical process of removing excess fat, is an elective procedure with rising frequency in the United States. Fat embolism syndrome is a clinical diagnosis and is defined as fat in the circulation with an identifiable clinical pattern of signs and symptoms (eg, hypoxemia, respiratory in...
journal_title：Archives of pathology & laboratory medicine
pub_type： 杂志文章,评审
doi：10.5858/arpa.2017-0117-RS
更新日期：2018-07-01 00:00:00
abstract：:Accurate assessment of tissues for hematolymphoid neoplasms requires an integrated multiparameter approach. Although morphologic examination by light microscopy remains the mainstay of initial assessment for hematolymphoid neoplasms, immunophenotypic analysis by immunohistochemistry and/or flow cytometry is essential ...
journal_title：Archives of pathology & laboratory medicine
pub_type： 杂志文章,评审
doi：10.5858/arpa.2016-0260-SA
更新日期：2017-03-01 00:00:00
abstract：:A family with a syndrome consisting of granulomatous arthritis, uveitis, and rash was first described in 1985. Another family with the same syndrome was described subsequently in 1990. The condition, in both families, is clinically different from sarcoidosis. To verify whether the granulomas in such patients also coul...
journal_title：Archives of pathology & laboratory medicine
pub_type： 杂志文章
doi：
更新日期：1993-10-01 00:00:00
abstract：:Loss of expression of the cell-cell adhesion molecule E-cadherin has been shown to have a potential role in the dedifferentiation and progression of many human malignancies. We applied immunohistochemical staining for E-cadherin to eight formalin-fixed, paraffin-embedded primary and matched metastatic human head and n...
journal_title：Archives of pathology & laboratory medicine
pub_type： 杂志文章
doi：
更新日期：1995-01-01 00:00:00
abstract：:Glomus tumor is a benign mesenchymal neoplasm comprising less than 2% of soft tissue tumors. It is composed of cells resembling modified smooth muscle cells of the normal glomus body. The glomus body, a thermoregulator, is a specialized form of arteriovenous anastomosis localized in dermal and precoccygeal soft tissue...
journal_title：Archives of pathology & laboratory medicine
pub_type： 杂志文章,评审
doi：10.1043/1543-2165(2008)132[1448:GT]2.0.CO;2
更新日期：2008-09-01 00:00:00
abstract：:Rosai-Dorfman disease is an idiopathic histiocytic disorder of lymph nodes and extranodal sites. Central nervous system manifestations of this disease are rare, and to our knowledge only 16 cases of intracranial involvement have been reported previously. Intracranial Rosai-Dorfman disease clinically and radiologically...
journal_title：Archives of pathology & laboratory medicine
pub_type： 杂志文章,评审
doi：
更新日期：1998-02-01 00:00:00
abstract：:The blood supply to the upper ventricular septum in the region of the conduction system is more abundant than the literature suggests. I found a significant arterial contribution to the upper ventricular septum from the proximal segment of the right coronary artery (RCA), or one of its early branches, in 77% of 65 hea...
journal_title：Archives of pathology & laboratory medicine
pub_type： 杂志文章
doi：
更新日期：1980-11-01 00:00:00
abstract：:A patient with a 100-g thymolipoma and myasthenia gravis experienced marked improvement in neuromuscular symptoms following removal of the tumor. Although 60 examples of thymolipoma have been reported, we believe that this is the first example of this tumor associated with myasthenia gravis. The clinical, radiologic, ...
journal_title：Archives of pathology & laboratory medicine
pub_type： 杂志文章
doi：
更新日期：1978-09-01 00:00:00
abstract：CONTEXT.—:Treatment of chronic viral hepatitis C (HCV) infection with direct-acting antiviral agents (DAAs) results in cure, or sustained viral response (SVR), in more than 90% of patients. However, there are subsets of patients who have persistent liver inflammation and fibrosis and develop hepatocellular carcinoma (H...
journal_title：Archives of pathology & laboratory medicine
pub_type： 杂志文章
doi：10.5858/arpa.2020-0008-OA
更新日期：2020-08-18 00:00:00
abstract：CONTEXT:There are 2 general types of assays measuring MUC1 gene-derived glycoprotein: assays for cancer antigen (CA) 15-3, which are sandwich assays, and assays for CA 27.29, which are competitive assays. These 2 types of assays measure slightly different parts of this tandem-repeat molecule. Across-method assay differ...
journal_title：Archives of pathology & laboratory medicine
pub_type： 杂志文章
doi：10.1043/1543-2165(2004)128<1131:MGGAFM>2.0.CO;2
更新日期：2004-10-01 00:00:00
abstract：:Transmission and scanning electron microscopic examinations were performed to evaluate the fine-structural differences in sinusoids of hepatocellular carcinoma, adenomatous hyperplasia of the liver, and fetal livers. In cancerous sinusoids, thickened endothelial cells with loss of sieve plates were conspicuous feature...
journal_title：Archives of pathology & laboratory medicine
pub_type： 杂志文章
doi：
更新日期：1992-01-01 00:00:00
abstract：:Campylobacter fetus is a fastidious, curved, Gram-negative bacillus that has been increasingly associated with human disease. To our knowledge, we are reporting the first documented case of C fetus sepsis associated with an aortic mycotic aneurysm. Typical of previously reported cases of infections caused by this orga...
journal_title：Archives of pathology & laboratory medicine
pub_type： 杂志文章
doi：
更新日期：1979-03-01 00:00:00
abstract：:Primary malignant melanoma of the larynx is a rare clinical entity. Only 53 cases have been reported in the medical literature to date. This report describes a case of primary malignant melanoma arising in the larynx and diagnosed by histologic examination of an excisional biopsy specimen. The patient was a 53-year-ol...
journal_title：Archives of pathology & laboratory medicine
pub_type： 杂志文章
doi：10.1043/0003-9985(2001)125<0271:PMMOTL>2.0.CO;2
更新日期：2001-02-01 00:00:00
abstract：:Just as electronic health records are transforming the practice of medicine and health care information management, practicing in the era of the electronic health record offers opportunities, if not imperatives, for pathologists to take on new and "transformative" professional and leadership roles for the organization...
journal_title：Archives of pathology & laboratory medicine
pub_type： 杂志文章
doi：10.5858/arpa.2013-0714-SO
更新日期：2015-03-01 00:00:00
abstract：CONTEXT:Dysregulation of mediators of apoptosis is associated with carcinogenesis. For biliary duct cancers, p53 gene mutation is an important contributor to carcinogenesis. Mutations in the p53 gene affect transcription of the Fas gene, resulting in lack of Fas expression on cell membrane. It has been previously shown...
journal_title：Archives of pathology & laboratory medicine
pub_type： 杂志文章
doi：10.1043/1543-2165(2005)129<481:ROAIC>2.0.CO;2
更新日期：2005-04-01 00:00:00
abstract：CONTEXT:The pyrimidine nucleoside analog, cytosine arabinoside (Ara-C), is an effective therapeutic agent for acute leukemia. The phosphorylated triphosphate, cytosine arabinoside triphosphate, competes with deoxycytosine triphosphate as a substrate for incorporation into DNA. Once incorporated into DNA, it inhibits DN...
journal_title：Archives of pathology & laboratory medicine
pub_type： 杂志文章
doi：10.1043/1543-2165(2004)128<1364:CASDTF>2.0.CO;2
更新日期：2004-12-01 00:00:00
abstract：CONTEXT:Lesions associated with monoclonal light and heavy chains display a variety of glomerular, tubular interstitial, and vascular manifestations. While some of the entities are well recognized, including light and heavy chain deposition diseases, AL (light chain) and AH (heavy chain) amyloidosis, and light chain ("...
journal_title：Archives of pathology & laboratory medicine
pub_type： 杂志文章,多中心研究
doi：10.5858/arpa.2013-0493-OA
更新日期：2014-10-01 00:00:00
abstract：OBJECTIVE:Bcl-2 and p53 genes may participate in a common pathway for regulation of apoptosis. The aims of this study were (1) to study the immunohistochemical expression of the bcl-2 oncoprotein in colorectal tumors, (2) to correlate it with that of p53 protein overexpression, and (3) to compare it with histopathologi...
journal_title：Archives of pathology & laboratory medicine
pub_type： 杂志文章
doi：
更新日期：1996-07-01 00:00:00
abstract：:An endobronchial papillary tumor in a 75-year-old reformed cigarette smoker exhibited the light microscopic features of a transitional cell neoplasm. The constituent cells showed cytologic features of malignancy; in addition, there were microfoci of mucosal invasion. Electron microscopy showed tonofilaments and numero...
journal_title：Archives of pathology & laboratory medicine
pub_type： 杂志文章
doi：
更新日期：1982-10-01 00:00:00
abstract：:We report a case of focal infection of the brain with cytomegalovirus (CMV) in a 14-year-old boy with metastatic lymphoepithelioma (nasopharyngeal carcinoma). Cytomegalovirus-bearing subependymal glia were only seen in the fourth ventricle, in close proximity to tumor cells, these were associated with an intense infla...
journal_title：Archives of pathology & laboratory medicine
pub_type： 杂志文章
doi：
更新日期：1979-07-01 00:00:00
abstract：:Two alpha-fucose-binding lectins, Ulex europaeus agglutinin I (UEA I) and Lotus tetragonolobus agglutinin, were employed to compare and contrast the distribution of fucosubstance in normal human kidneys and a variety of renal tumors. The study employed a total of 31 kidneys surgically removed for the presence of a var...
journal_title：Archives of pathology & laboratory medicine
pub_type： 杂志文章
doi：
更新日期：1988-09-01 00:00:00
abstract：:The efficacy of two new monoclonal antibodies with cell lineage-restricted reactivity (HMB-45 [melanocytes] and anti-synaptophysin [neuroepithelial cells]) was compared with that of "traditional" antibody panels in the delineation of malignant melanoma (MM) of the sinonasal region, nasopharyngeal carcinoma (NPC), and ...
journal_title：Archives of pathology & laboratory medicine
pub_type： 杂志文章
doi：
更新日期：1988-06-01 00:00:00
abstract：:Human anti-mouse antibodies (HAMA) are human immunoglobulins with specificity for mouse immunoglobulins. This topic currently is of interest because of the increased use of monoclonal mouse antibodies as diagnostic reagents both for in vitro laboratory measurements and for in vivo imaging studies. Monoclonal mouse ant...
journal_title：Archives of pathology & laboratory medicine
pub_type： 杂志文章,评审
doi：10.1043/0003-9985(2000)124<0921:HAMA>2.0.CO;2
更新日期：2000-06-01 00:00:00
abstract：:Congenital syphilis remains a public health concern in the United States. Infants whose mothers are treated in the third trimester without adequate prenatal care have an increased risk of morbidity and mortality in the immediate perinatal period. The identification of Treponema pallidum in tissue is definitive confirm...
journal_title：Archives of pathology & laboratory medicine
pub_type： 杂志文章
doi：10.1043/0003-9985(2002)126<0484:PAICS>2.0.CO;2
更新日期：2002-04-01 00:00:00
