Eight Pearls for Reducing Errors in Eye Pathology

Patient safety has become a major topic of interest since the publication of the Institute of Medicine’s landmark on medical errors in the United States in 1999.¹ This benchmark report used published data concerning the frequency of medical errors in the United States. The findings showed that medical errors accounted for between 44,000 and 98,000 deaths per year nationwide and that medical errors cost payers, including the U.S. government, between $17 billion and $29 billion annually. Additionally, medical errors increase costs, induce patient harm and may result in the loss of your medical license.

For all of these reasons, nearly all medical specialty organizations have taken steps to promote education about patient safety and to reduce medical errors.

One area ophthalmology in particular is focusing on is eye pathology. In this field, clinicians send specimens out for analysis because they are concerned that something serious is happening within their patient. Any errors made during the collection, fixation, transfer, accessioning, processing or microscopic readout of the specimen may delay the diagnosis or even result in the wrong diagnosis. If the patient has an aggressive tumor, this can lead to severe morbidity or even mortality.

The goal of this article is to refresh your knowledge of the proper handling of specimens and provide you with high-yield guidelines to reduce your risk of errors. Residents preparing for their ocular pathology rotation should use the online eye pathology manual of Ben Glasgow, MD.

Ocular Pathology Specimen Guidelines

These guidelines will keep you out of trouble with ocular pathology specimens:

1. Properly label the specimen. It is important that the patient name, identifying number and specimen name are the same on both the pathology requisition form and the specimen bottle. When labeling the specimen, make sure to indicate if the specimen came from the right or left side, as well as its location e.g. “right upper lid lesion”.
2. Provide enough clinical history. While a long narrative is not necessary, there should be enough clinical history to guide the ocular pathologist. A bad narrative is “84-year-old man with lid lesion.” A good narrative is “84-year-old man with six-month growth of right upper lid lesion exhibiting lash loss and destruction of lid margin. Please rule out malignancy.”
3. Properly fix the specimen. Proper fixation is of paramount importance in processing tissue for histopathological evaluation. Tissue is fixed in 10 percent formalin and immersed in a minimum of 10 times its volume of fixative.
   
   For conjunctival specimens, make sure to flatten out the specimen on tissue paper, with the epithelial side facing upwards, before placing the specimen in fixative. Certain specimens cannot be fixed, in which cases fresh tissue should be sent to the eye pathologist. For instance, a vitreous biopsy for intraocular lymphoma requires the specimen to be sent directly to the pathologist for processing. Because the vitreous biopsy is not fixed, this sample cannot be mailed or delivered by courier. I have seen cases of intraocular lymphoma delayed for over a year because of improper handling of the vitreous biopsy. When in doubt, call the ocular pathologist and speak with the physician directly.
4. Mark the margins clearly. When removing a lesion that requires analysis of the surgical margins, it is important to clearly mark the margins. In a pentagonal lid resection, it is enough for the clinician to state right or left and upper or lower lid lesion because the orientation of the lashes will identify the lateral and medial surgical margins. For clarity, you may place a 7-O suture to mark either the lateral or medial margin. Indicate on the pathology requisition form where the suture is placed, e.g. “7-0 nylon suture placed on lateral margin.” For conjunctival and skin lesions, use two different types of sutures to mark adjacent surgical margins, such as a 7-0 prolene suture for the superior margin and 7-0 nylon suture for the medial margin. If you can, place the specimen in the container and identify the surgical margins using your sutures after removing it. That way, the ocular pathologist will be able to do the same.
5. Submit one specimen in one specimen container. Do not mix specimens from different locations in one container, even if they are from the same patient. For instance, you will be in a predicament if you place lesions from all four eyelids in one container, and one of the skin tags submitted turns out to be a basal cell carcinoma. To be safe, it is wise to place one specimen in one container. If a small area has multiple lesions, such as the medial left lower lid, then it is OK to place all the specimens from this small area into one specimen container.
6. Develop good communication with the ocular pathologist. Most errors can be alleviated with proper communication. When in doubt, or if you need special consideration, contact the ocular pathologist or clearly indicate your concerns on the pathology requisition form.
7. Submit enough tissue and properly handle the specimen. Inadequate amount of specimen makes diagnosis extremely difficult. Also, avoid cauterization and crushing of the specimen, which will result in artifacts that obscure analysis.
8. Keep a log book and follow up with your patients. I have seen patients who have had their lid lesion removed and thought they were cured, only to return months later with an invasive cancer—all due to poor follow-up. To stay on track of your patients, it is a good idea to keep a logbook of all the patients you biopsy. When you receive the pathology report, write down the diagnosis in the log book and indicate if the patient requires a call-back or follow-up. Each week, review your log book to make sure biopsies have been evaluated by the eye pathologist.

Regardless of your subspecialty or whether you are a comprehensive ophthalmologist, you will occasionally find yourself in a position to evaluate, excise and manage ocular lesions. Try to adhere to these guidelines. They will enable you to provide better care for your patients and reduce your risks of making errors.

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About the author: Andrew Doan, MD, PhD, is a staff ophthalmologist at the Naval Medical Center, San Diego, as well as an assistant professor of surgery for the Uniformed Services University of the Health Sciences. He is also an assistant clinical professor at Loma Linda University in California. Disclaimer: The views expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense or the United States Government.

¹Kohn LT, Corrigan JM, Donaldson MS, eds. To Err Is Human: Building a Safer Health System. Washington, D.C.: National Academy Press; 1999.