Colgan Terence J
Department of Pathology and Laboratory Medicine, Mount Sinai Hospital, Toronto, Ontario, Canada.
J Low Genit Tract Dis. 2005 Oct;9(4):216-8. doi: 10.1097/01.lgt.0000179860.67574.22.
Full disclosure of medical errors to patients is now widely seen as an essential component of error management, although its update into daily clinical practice is variable. Laboratory diagnostic errors are discovered in retrospective reviews of previous surgical and cytopathology cases. This quality assurance practice is a valuable tool of practice audit and change for both cytotechnologists and pathologists. Presently, these diagnostic errors are only reported to the clinician and patient if the new finding affects current patient management. Mandatory full disclosure of all diagnostic errors discovered in the retrospective review process would have a significant adverse impact on cytotechnologists, pathologists, the laboratory, the clinic, the institution, and insurers. Retrospective pathology review would become so burdensome that its survival would be in jeopardy-unless measures are undertaken to ameliorate the anticipated adverse consequences.
向患者全面披露医疗差错如今被广泛视为差错管理的一个重要组成部分,尽管其在日常临床实践中的推广情况参差不齐。实验室诊断差错是在对既往手术和细胞病理学病例的回顾性审查中发现的。这种质量保证做法对于细胞技术人员和病理学家而言,是实践审核与改进的一项宝贵工具。目前,只有当新发现影响到当前患者的治疗时,这些诊断差错才会报告给临床医生和患者。在回顾性审查过程中强制全面披露所有发现的诊断差错,将对细胞技术人员、病理学家、实验室、诊所、机构和保险公司产生重大不利影响。回顾性病理审查将变得如此繁重,以至于其存续将受到威胁,除非采取措施减轻预期的不良后果。