Safety practices in surgical pathology: practical steps to reduce error in the pre-analytic, analytic, and post-analytic phases of surgical pathology

The production and interpretation of a haematoxylin-eosin stained slide from a patient specimen is a complex, multi-step process. An error within any of the steps may cause patient harm. The steps in this process can be divided into the pre-analytic, analytic and post-analytic phases. This paper will review benchmarking and published error rates, where available, across all three phases. Practical, evidence-based, methods to reduce errors in all three phases will be discussed with emphasis placed upon the benefits and limits of benchmarking and six-sigma. The concept of striving for zero defects through lean production methods and the Toyota Production System will be discussed as it applies to all three phases of surgical pathology.