Review article: practical current issues in perioperative patient safety.

PURPOSE: This brief review provides an overview and, importantly, a context perspective of relevant current practical issues in perioperative patient safety. PRINCIPAL FINDINGS: The dramatic improvement in anesthesia patient safety over the last 30 years was not initiated by electronic monitors but, rather, largely by a set of behaviours known as "safety monitoring" that were then made decidedly more effective by extending the human senses through electronic monitoring, for example, capnography and pulse oximetry. In the highly developed world, this current success is threatened by complacency and production pressure. In some areas of the developing/underdeveloped world, the challenge is implementing the components of anesthesia practice that will bring safety improvements to parallel the overall current success, for instance, applying the World Federation of Societies of Anaesthesiologists (WFSA) "International Standards for A Safe Practice of Anaesthesia". Generally, expanding the current success in safety involves many practical issues. System issues involve research, effective reporting mechanisms and analysis/broadcasting of results, perioperative communication (including "speaking up to power"), and checklists. Monitoring issues involve enforcing existing published monitoring standards and also recognizing the risk of danger to the patient from hypoventilation during procedural sedation and from postoperative intravenous pain medications. Issues of clinical care include medication errors in the operating room, cerebral hypoperfusion (especially in the head-up position), dangers of airway management, postoperative residual weakness from muscle relaxants, operating room fires, and risks specific in obstetric anesthesia. CONCLUSIONS: Recognition of the issues outlined here and empowerment of all anesthesia professionals, from the most senior professors and administrators to the newest practitioners, should help maintain, solidify, and expand the improvements in anesthesia and perioperative patient safety.

The Anesthesia Patient Safety Foundation at 25: a pioneering success in safety, 25th anniversary provokes reflection, anticipation.

The Anesthesia Patient Safety Foundation (APSF) was created in 1985. Its founders coined the term "patient safety" in its modern public usage and created the very first patient safety organization, igniting a movement that is now universal in all of health care. Driven by the vision "that no patient shall be harmed by anesthesia," the APSF has worked tirelessly for more than a quarter century to promote safety education and communication through its widely read Newsletter, its programs, and its presentations. The APSF's extensive research grant program has supported a great many projects leading to key safety improvements and, in particular, was central in the development of high-fidelity mannequin simulation as a research and teaching tool. With its pioneering collaboration, the APSF is unique in incorporating the talents and resources of anesthesia professionals of all types, safety scientists, pharmaceutical and equipment manufacturers, regulators, liability insurance companies, and also surgeons. Specific alerts, campaigns, discussions, and projects have targeted a host of safety issues and dangers over the years, starting with minimal intraoperative monitoring in 1986 and all the way up to beach-chair position cerebral perfusion pressure, operating room medication errors, and the extremely popular DVD on operating room fire safety in 2010; the list is long and expansive. The APSF has served as a model and inspiration for subsequent patient safety organizations and has been recognized nationally as having a dramatic positive impact on the safety of anesthesia care. Recognizing that the work is not over, that systems, organizations, and equipment still at times fail, that basic preventable human errors still do sometimes occur, and that "production pressure" in anesthesia practice threatens past safety gains, the APSF is firmly committed and continues to work hard both on established tenets and new patient safety principles.

An interview with John H. Eichhorn. Interview by Joseph Conigliaro.

Anesthesiology, with its development of practice standards, helped create the patient safety movement, states Dr. Eichhorn, and "can continue to be the role model and to lead the way in patient safety for all of health care.

An iterative process of global quality improvement: the International Standards for a Safe Practice of Anesthesia 2010.

PURPOSE: To enhance patient safety through contemporaneous and comprehensive standards for a safe practice of anesthesia that augment, enhance, and support similar standards already published by various countries and that provide a resource for countries that have yet to formulate such standards. STANDARDS DEVELOPMENT: The Safe Anesthesia Working Group of the World Health Organization's "Safe Surgery Saves Lives" global initiative updated the 1992 International Standards for the Safe Practice of Anaesthesia (Standards) through an iterative process of literature review, consultation, debate, drafting, and refinement. These Standards address, in detail, the organization, support, practices, and infrastructure for anesthesia care. The Standards are grounded in the fundamental principle of safety in anesthesia, i.e., the continuous presence of an appropriately trained, vigilant anesthesia professional. In effect, the use of pulse oximetry during anesthesia is now considered mandatory, with acknowledgement that compromise may be unavoidable in emergencies. At the World Congress of Anaesthesiologists in 2008, drafts were presented for comment, further refinements were made, and the Revised Standards were adopted by the World Federation of Societies of Anaesthesiologists (WFSA). These Revised Standards were posted on the WFSA website for further feedback, and minor revisions followed. The International Standards for a Safe Practice of Anesthesia 2010 were endorsed by the Executive Committee of the WFSA in March 2010. Ongoing periodic revision is planned. CONCLUSION: While they are universally applicable, the 2010 Standards primarily target lesser-resourced areas. They are designed particularly for regions that have yet to formulate or adopt their own standards so as to promote optimum patient outcomes in every anesthetizing location in the world.

Check Sample Abstracts.

The following abstracts are compiled from Check Sample exercises published in 2008. These peer-reviewed case studies assist laboratory professionals with continuing medical education and are developed in the areas of clinical chemistry, cytopathology, forensic pathology, hematology, microbiology, surgical pathology, and transfusion medicine. Abstracts for all exercises published in the program will appear annually in AJCP.

Internet-based gynecologic telecytology with remote automated image selection: results of a first-phase developmental trial.

A retrospective set of 191 gynecologic cytology slides with reference interpretations was run on an automated screening device that selects fields of view (FOVs) based on a hierarchical probability of abnormality being present. An interface was developed between the device and a remote server using customized image review software. FOVs were reviewed by 3 cytotechnologists and 3 cytopathologists, and binary triage (unsatisfactory for evaluation/negative for intraepithelial lesion or malignancy [NILM] vs "abnormal" [neither unsatisfactory nor NILM]) and specific interpretations were done. No morphologic training before FOV review was provided. Three or more reviewers agreed on the correct categorization of NILM/unsatisfactory in 89% (85/96) and abnormal in 83% (79/95). Three or more reviewers triaged cases to abnormal as follows: atypical squamous cells of uncertain significance, 83% (5/6); atypical squamous cells, cannot exclude high-grade lesion, 100% (3/3); low-grade squamous intraepithelial lesion (SIL), 83% (52/63); high-grade SIL, 94% (17/18); and atypical glandular cells, 40% (2/5). This procedure may have comparable sensitivity and specificity and possibly could provide effective initial triage to further evaluation. A review of individual cases suggests that further accuracy can be achieved with additional training and experience.

A novel automated screening and interpretation process for cervical cytology using the internet transmission of low-resolution images: a feasibility study.

BACKGROUND: Transmission over the Internet of low-resolution images acquired by automated screening of cervical cytology specimens has the potential to provide remote interpretation and, hence, centralization of a cytology workforce. METHODS: Liquid-based cervical cytology slides were scanned using the FocalPoint(R) System. Ten black-and-white images that had the greatest probability of containing abnormality were acquired from each of 32 reference slides (16 negative samples, 3 samples of atypical squamous cells of uncertain significance, 5 samples of low-grade squamous intraepithelial lesions [LSIL], 5 samples of high-grade squamous intraepithelial lesions [HSIL], 1 adenocarcinoma in situ sample, and 2 carcinoma samples) and were transmitted as e-mail attachments in JPEG format to remote reading stations. The slides were interpreted independently by two pathologists and were assigned to either of two groups: 1) suspicious for >or=HSIL or 2)

The negative predicative value of breast fine-needle aspiration biopsy: the Massachusetts General Hospital experience.

Breast fine-needle aspiration biopsy (FNAB) has been increasingly accepted as an important triage tool for the evaluation of breast lumps. We examined the clinical utility and diagnostic accuracy of a negative breast FNAB result by studying 450 breast aspirates in 413 patients (average age 45 years) with a "negative" or benign cytologic interpretation performed at Massachusetts General Hospital over a 4-year period. Of these patients, 121 (29%) underwent subsequent biopsy and 17 (4%) were found to have malignancy (3% of total negative FNABs; 14% with histology). None of these 17 patients had a triple negative test. A cohort of 115 patients had documentation of negative physical, radiologic, and cytologic examinations (the triple negative), none of whom were found to have malignancy on histologic or at least 2-year clinical follow-up (negative predictive value [NPV] = 100% with a triple-negative test). Outside of the triple-negative test, the NPV of a negative breast FNAB is reduced with a false-negative rate of 7%. However, in the setting of a triple-negative test, the NPV in our patient population was 100%, reassuring the patient and clinician that clinical follow-up and not surgical intervention was sufficient for proper patient care.

Medullary carcinoma, provocative now as then.

The recent observation that studies of BRCA1-associated tumors contain a high proportion of medullary carcinomas and ductal carcinomas with medullary features has re-introduced pathologists to an old diagnostic problem. The term "medullary carcinoma" dates to the 19th century, but the modern entity was introduced in 1949 by Moore and Foote, who described a carcinoma with a lymphoid infiltrate, a favorable prognosis, and low frequency of metastasis. Almost three decades later, Ridolfi et al proposed specific criteria for diagnosis, resulting in an entity with an even more favorable prognosis and a lower incidence. The reproducibility and clinical relevance of the diagnosis have been questioned recently, and new criteria have been proposed and compared. The tumors typically express cytokeratin 7, often vimentin and S100-protein, but not cytokeratin 20. The usual ones are positive for p53 and negative for estrogen receptor, Her2/neu, and bcl-2. Medullary carcinomas express e-cadherin and beta-catenin more often than ordinary high-grade ductal carcinomas, and the former have genetic differences from the latter. The lymphoid infiltrate of medullary carcinomas is related to beta-actin fragments exposed by apoptotic cells. The present review discusses historical and recent developments and emphasizes diagnostic criteria.

Transitional cell carcinoma of the ovary: a morphologic study of 100 cases with emphasis on differential diagnosis.

Transitional cell carcinoma (TCC) of the ovary is a recently recognized subtype of ovarian surface epithelial-stromal cancer, and studies of its morphology are few. As a result, the criteria for its diagnosis and spectrum of its morphology are not clearly established. One hundred consecutive consultation cases of ovarian carcinoma with a pure or partial transitional cell pattern (excluding malignant Brenner tumor) diagnosed between 1989 and 2001 were evaluated for the frequency of various pathologic features and the relation of TCC to other surface epithelial-stromal carcinomas. The women were 33 to 94 years of age (mean, 56 years). A total of 47 tumors were stage I, 21 stage II, 31 stage III, and 1 stage IV; 13% of the stage I tumors and 41% of tumors of all stages were bilateral. The tumors ranged from 3.0 to 30 cm in greatest dimension (mean, 10 cm); 60% of them were solid and cystic, 24% solid, and 16% cystic. TCC was the exclusive or predominant component in 93% of the tumors and showed undulating (93%), diffuse (57%), insular (55%), and trabecular (43%) patterns. In four tumors with an insular growth, the pattern focally mimicked a Brenner tumor. Necrosis was present in 57% of the cases. Features that were seen in the tumors that in aggregate produced a relatively consistent appearance were "punched out" microspaces (87%), often the size of Call-Exner bodies, large cystic spaces (73%), and large blunt papillae (63%). Features that were sometimes seen, usually as a focal finding, included slit-like fenestrations (49%), bizarre giant cells (35%), small filiform papillae (18%), gland-like tubules (17%), squamous differentiation (13%), and psammoma bodies (4%). In 23 cases, TCC was a component of a mixed epithelial carcinoma, the additional components being serous adenocarcinoma in 16, endometrioid in 5, mucinous in 1, and clear cell carcinoma in 1. The tumor cells of the TCC component often were relatively monomorphic; 6% of the tumors were grade 1, 43% grade 2, and 51% grade 3. The nuclei were oblong or round and often had large single nucleoli (69%) or longitudinal grooves (48%). The cytoplasm was typically pale and granular but was rarely strikingly clear or oxyphilic. TCC of the ovary usually occurs in pure form but is also common as a component of a surface epithelial carcinoma of mixed cell type. In either situation, TCC has a constellation of architectural and cytologic features that readily distinguish it in most cases from other types of ovarian cancer. Recognition of these features will lead to a more consistent diagnosis of this tumor and aid in determining whether it has distinctive clinical features, particularly with regard to its behavior.