ࡱ> :=9 bjbj .i1gi1g  8,*:::,,,,,,,$.q1\6,:::::6,4K,:F,:,)|0+~\R4*+a,0,F*1R1$0+0+1D+:::::::6,6,$:::,::::1::::::::: X H: Case study template for patient safety bulletins Case study title Dont ever assume. What happened and what were the issues/implications? A trainee and consultant were reviewing a case of a biopsy specimen. It appeared to be a high grade poorly differentiated tumour which was typical of the location where the biopsy had been taken, and both the trainee and consultant had seen many such examples before. Immunohistochemistry was felt to be unnecessary in this case and would not be of any particular value as there were no obvious questions associated with it. The diagnosis was therefore reported. However, a lymph node from this patient had also been biopsied and had been reviewed by another pathologist. Immunohistochemistry confirmed that the diagnosis was in fact a metastatic malignant melanoma. This information (regarding the past medical history and additional lymph node biopsy) had not been stated on the request form. The original biopsy was then re-reviewed and subsequent immunohistochemistry confirmed that this was also malignant melanoma. What actions were taken? This error was identified early enough to ensure that there were no issues that impacted on the patient. The correct diagnosis was communicated to the clinicians and they were able to proceed with the appropriate management for such a scenario. The extensive experience of the pathologist drove their decision to make the original diagnosis without confirming with immunohistochemistry or considering other differentials for a poorly differentiated tumour in this location. A pathologist needs to trust their opinion and have the self-confidence necessary to make a diagnosis, but also needs to remember that there are also other possibilities and although a tumour may appear to show the expected appearance, it is always worth checking and confirming. What did you learn? A pathologist should always seek to confirm the diagnosis that they suspect, and always consider malignant melanoma in the differential diagnosis of a poorly differentiated tumour. It is one of the big mimickers in pathology; dont get caught out! It also highlights the need for a guideline as to how to work-up and report poorly differentiated tumours. This guideline could include a checking procedure, for example the review of the case by a second consultant before it is finally reported. How was the learning shared? The case was placed in the interesting cases section for trainees to review.      012BCVWXC c \ ] ) - 9  * + vvlvX'hehW*5B* OJQJ\^Jphph1QOJQJ^JhkEOJQJ^JheheOJQJ^Jheh NOJQJ^Jheh=3OJQJ^JhehOJQJ^JhehaOJQJ^J'heha5B* OJQJ\^JphphW*5B* CJ\aJphphah]5CJ(haha5CJ( h'$5CJ(12CWX\ ] * + , - F < = ;<=QDEFc $^a$gde$a$gdegda$a$gda+ , - E F < = J i  :;<=PQ}lbUA4heh=3OJQJ^J'hehW*5B* OJQJ\^JphpheheOJQJ^Jh NOJQJ^J heh NCJOJQJ^JaJ hehzCJOJQJ^JaJheCJOJQJ^JaJ hehCJOJQJ^JaJ$hehaB*OJQJ\^JphhehOJQJ^JhehaOJQJ^J'heha5B* OJQJ\^Jphp!he5B* OJQJ\^JphpCDEFcǴﴴh&Uhah~sjh~sUheh15OJQJ^Jheh1OJQJ^J$heh=35B* OJQJ^JphpheheOJQJ^Jh1OJQJ^J heh1CJOJQJ^JaJ hehCJOJQJ^JaJ'cgda$a$gde $^a$gde$a$gde,1h. A!"#$% x666666666vvvvvvvvv666666>6666666666666666666666666666666666666666666666666hH66666666666666666666666666666666666666666666666666666666666666666p62&6FVfv2(&6FVfv&6FVfv&6FVfv&6FVfv&6FVfv&6FVfv8XV~ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@66666 OJPJQJ_HmH nH sH tH @`@ aNormalCJ_HaJmH sH tH DA D Default Paragraph FontRiR 0 Table Normal4 l4a (k ( 0No List tt ap Table Grid7:V0 d4@4 a0Header  B#:/: a0 Header Char OJQJ^J4 @"4 a0Footer  B#:/1: a0 Footer Char OJQJ^J6U A6 a0 Hyperlink >*B*phcHRH (0 Balloon TextCJOJQJ^JaJR/aR (0Balloon Text CharCJOJQJ^JaJtH $/q$ =3h235\\@\  List Paragraph ^m$CJOJPJQJ^JaJPK![Content_Types].xmlN0EH-J@%ǎǢ|ș$زULTB l,3;rØJB+$G]7O٭Vj\{cp/IDg6wZ0s=Dĵw %;r,qlEآyDQ"Q,=c8B,!gxMD&铁M./SAe^QשF½|SˌDإbj|E7C<bʼNpr8fnߧFrI.{1fVԅ$21(t}kJV1/ ÚQL×07#]fVIhcMZ6/Hߏ bW`Gv Ts'BCt!LQ#JxݴyJ] C:= ċ(tRQ;^e1/-/A_Y)^6(p[_&N}njzb\->;nVb*.7p]M|MMM# ud9c47=iV7̪~㦓ødfÕ 5j z'^9J{rJЃ3Ax| FU9…i3Q/B)LʾRPx)04N O'> agYeHj*kblC=hPW!alfpX OAXl:XVZbr Zy4Sw3?WӊhPxzSq]y 4 +  c @ @H 0(  0(  B S  ?  32C 22BBVVbc)**+-F<=:;<PPQC D E c .4hBwR( 81PV!xX7n_\?lph^`OJQJo(hHh^`OJQJ^Jo(hHohp^p`OJQJo(hHh@ ^@ `OJQJo(hHh^`OJQJ^Jo(hHoh^`OJQJo(hHh^`OJQJo(hHh^`OJQJ^Jo(hHohP^P`OJQJo(hHh8^8`OJQJo(hHh^`OJQJ^Jo(hHoh ^ `OJQJo(hHh ^ `OJQJo(hHhx^x`OJQJ^Jo(hHohH^H`OJQJo(hHh^`OJQJo(hHh^`OJQJ^Jo(hHoh^`OJQJo(hH ^`OJQJo(^`OJQJ^Jo(o p^p`OJQJo( @ ^@ `OJQJo(^`OJQJ^Jo(o ^`OJQJo( ^`OJQJo(^`OJQJ^Jo(o P^P`OJQJo(80^8`0OJPJQJ^Jo(" ^`OJQJ^Jo(hHop^p`OJQJo(hH@ ^@ `OJQJo(hH^`OJQJ^Jo(hHo^`OJQJo(hH^`OJQJo(hH^`OJQJ^Jo(hHoP^P`OJQJo(hHh^`OJQJo(hHh^`OJQJ^Jo(hHohp^p`OJQJo(hHh@ ^@ `OJQJo(hHh^`OJQJ^Jo(hHoh^`OJQJo(hHh^`OJQJo(hHh^`OJQJ^Jo(hHohP^P`OJQJo(hH ^`OJQJo(^`OJQJ^Jo(o p^p`OJQJo( @ ^@ `OJQJo(^`OJQJ^Jo(o ^`OJQJo( ^`OJQJo(^`OJQJ^Jo(o P^P`OJQJo(7n_PV!wR.4h?l                            m                          W)('<t S 1w%(`+&C,=3%]CkE N1Q3Q&U6p~s@1Table1WordDocument .SummaryInformation()DocumentSummaryInformation81MsoDataStore0.~\~\FRPIEVHEEJQ4Q==2P|~\~\Item 2PropertiesUCompObj r   F Microsoft Word 97-2003 Document MSWordDocWord.Document.89q