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C. D. Christou et al.
when the balance between them is unclear, physicians will naturally adopt a proactive stance. Therefore, guidelines will continue to recommend the enforcement of
these practices until high-quality evidence suggests otherwise. Nevertheless, due to
this eld’s nature, large-scale randomized clinical trials on these topics are highly
unlikely to occur. As a result, myth and reality will most probably continue to coexist for the imminent future.
Unfortunately, based on the various reports included in this chapter, the idea
that the OR is currently a safe, calm, ideal environment to work in is more ction
than reality. OR members continuously face a plethora of potential hazards in the
OR. Besides physical harm, OR members encounter multiple psychological
challenges, including stress and disruptive behavior. Disruptive behavior should
not be tolerated. Professionalism and communication skills are among the core
competencies listed by the American Board of Medical Specialties and the
Accreditation Council for Graduate Medical Education [149, 150]. We envision
a future where professionalism and social skills will be considered as equally
important as surgical skills. Healthcare facilities should be proactive regarding
disruptive behavior and adopt measures that ameliorate the effects of factors that
lead to disruptive behavior, such as emotional stress, before compromising the
OR personnel’s performance. Prevention is the most critical step toward addressing disruptive behavior [151]. Preventive measures could include team training,
standardized communication techniques, and the use of checklists at critical
times, which improve team communication, promote respect and familiarity
among team members, and empower the OR members to speak up [143, 152,
153]. An unhealthy environment during training could lead to a future disruptive
physician; thus, professionalism and communication skills should be a vital part
of the training. The performance of a surgeon during training should be evaluated, targeting these particular skills. Finally, monitoring systems and quality
control measures that quickly identify and address potential liabilities should be
implemented by healthcare facilities to ensure a safe and efcient environment
for all the OR inhabitants.
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Handling Surgical Specimens
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toDecrease Errors inPathology
FouadBoulos andMichelAttieh
Introduction
The discipline of pathology is one that largely takes place behind the scenes and is
commonly misunderstood by members of the clinical teams. Its role is often reduced
to the simple examination of tissue and subsequent issuing of a diagnosis. Although
this view represents the essence of what a pathologist is trained to do, it would be a
mistake to oversimplify the procedural complexities of diagnostic surgical pathology. The process of obtaining a diagnosis from a surgical specimen is multifaceted
and suffers from a myriad of potential sources of error, any one of which can entirely
compromise the accuracy of the end result. These errors can occur at any number of
junctures, from the admission of the patient to the hospital until the issuing of the
nal pathology report. In order to better grasp when and how problems may arise, it
serves to divide these steps into three distinct stages. The rst is the pre-analytical
stage, which involves everything that takes place prior to the receipt of the specimen
in the pathology department. The second is the analytical stage, which involves the
laboratory work including tissue xation, processing, staining, and interpretation.
The third and last is the post-analytical and probably the least complex stage, which
involves the drafting and issuing of the nal pathology report. Although errors tend
to be blamed on the analytical and post-analytical stages of the diagnostic process,
many preventable errors occur before the specimen even reaches the pathology lab,
contributing either to downright mistakes or to unnecessary delays in the diagnosis
and management of patients.
10
F. Boulos
Department of Pathology and Immunology, Washington University in St. Louis,
St. Louis, MO, USA
M. Attieh (*)
Department of Anatomical Pathology and Laboratory Medicine, American University of
Beirut Medical Center, Beirut, Lebanon
© Springer Nature Switzerland AG 2024
J. J. Hoballah et al. (eds.), Principles of Perioperative Safety and Efciency,
https://doi.org/10.1007/978-3-031-41089-5_10
155
156
https://t.me/med1917
This chapter will focus on the pre-analytical phase of the diagnostic process, listing the potential scenarios where mistakes are likely to occur, and proposing solutions and approaches designed to decrease the frequency and severity of human error.
Although it is quite natural to think of errors in pathology as representing incorrect diagnoses, we believe in expanding the denition of error to encompass actions
that result in unnecessary expenses, delays, and confusion, even if they are eventually resolved and an accurate diagnosis is ultimately rendered. Thankfully, the number of instances where a wrong diagnosis is given because of a breakdown of the
procedural steps is low. However, the number of instances where a wrong diagnosis
could have been given had the pathologists not taken the adequate steps to acquire
and verify informational elements that were lacking—or did not fulll reasonable
expectations—is quite high, in our experience. These shortfalls should therefore be
regarded as signicantly disruptive elements resulting in inefcient or inaccurate
outcomes, and all such instances that contribute to the possibility of error should be
addressed and remedied individually and systematically.
We shall proceed to divide the pre-analytical phase into its constituent parts, each
of which will be analyzed in a separate section. The sections are as follows: patient
identication, communication between clinician and pathologist, clinical history,
tissue identication and orientation, tissue preservation, and tissue transportation [1, 2].
F. Boulos and M. Attieh
Patient Identification
Proper patient identication is without a doubt the most fundamental measure to
ensure appropriate medical care [3]. A detailed discussion of patient identication
procedures is beyond the scope of this chapter, as it will be addressed elsewhere in
this textbook. However, patient identication goes beyond doing the correct procedure on the correct patient. It also and very importantly involves the proper identication of the specimens taken from the patients for laboratory testing and pathology
examination [4–6]. The greatest number of pre-analytical mistakes related to pathology, based on large studies of thousands of patients, appears to reside in inadequate
or inaccurate patient and specimen identication [7, 8]. It has become standard
practice by the College of American Pathologists (CAP), Joint Commission
International (JCI), and other regulatory agencies’ standards to include at least two
different identiers on every patient; this aims to preempt patient mix-up when two
different patients have similar identifying information like name, date of birth, or
medical record number [9, 10]. The greater the number of identiers, the lower the
likelihood of identier overlap between two patients. Despite these measures, a
common source of specimen mislabeling is batching of specimens and labeling
multiple containers in anticipation of a specic procedure, instead of preparing each
container for each procedure separately to avoid specimen and container mix-up.
Although batching containers across patients is rarely an issue in operating rooms,
given the necessary separation and time between procedures, batching the preparation of containers for different specimens on the same patient is common practice.
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