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Objective: Information contained in request forms for histopathological examinations plays a critical role in the microscopic interpretation of tissue changes. Despite its importance, studies have shown inadequacies in the information communicated by clinicians. This study aimed to determine how well the necessary information is provided on the histopathology request forms and to compare its variability among different departments of a hospital. Material and Method: A retrospective, 3-month, cross-sectional study was conducted to evaluate all consecutive histopathology request forms received from different departments of a tertiary, academic hospital for three months, regarding the documentation of 12 criteria. Results: None of the 2040 requests received had all the required items. Four items of specimen description, laboratory and imaging findings, and physician contact number were available only in less than 12.5% (range between 0.05 to 12.45%) of the requests. However, four other items of patient name and contact number, physician name, and anatomical site of the lesion were documented in more than 90%. The median number of the documented items was the highest in the surgery and orthopedics (9 items) and the lowest in the pulmonology department (7 items). Comparison between departments showed that the documentation of items in the surgery department were significantly better than that of the ENT, urology, and internal medicine departments (p

Objective: Information contained in request forms for histopathological examinations plays a critical role in the microscopic interpretation of tissue changes. Despite its importance, studies have shown inadequacies in the information communicated by clinicians. This study aimed to determine how well the necessary information is provided on the histopathology request forms and to compare its variability among different departments of a hospital. Material and Methods: A retrospective, 3-month, cross-sectional study was conducted to evaluate all consecutive histopathology request forms received from different departments of a tertiary, academic hospital for three months, regarding the documentation of 12 criteria. Results: None of the 2040 requests received had all the required items. Four items of specimen description, laboratory and imaging findings, and physician contact number were available only in less than 12.5% (range between 0.05 to 12.45%) of the requests. However, four other items of patient name and contact number, physician name, and anatomical site of the lesion were documented in more than 90%. The median number of the documented items was the highest in the surgery and orthopedics (9 items) and the lowest in the pulmonology department (7 items). Comparison between departments showed that the documentation of items in the surgery department were significantly better than that of the ENT, urology, and internal medicine departments (p<0.001). Also, the internal medicine department was significantly different from all other departments (p<0.001) except neurosurgery (p=0.88). Conclusion: Our results point out a serious gap in the adequacy of pathology request forms, especially clinical items. Given the implication of such information to ensure patient safety, further studies are recommended to evaluate the impact of educational and supportive computerized interventions such as clinician education and barcoding and specimen tracking systems to help fill in the required items completely. [ABSTRACT FROM AUTHOR]

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Background: Laboratory request form is an important means of interaction between clinicians and laboratory service providers. The omission of information on the request form may result in laboratory errors which may have a negative impact on patients’ outcome. Objective: To assess the pattern of completion of laboratory request forms in a tertiary facility. Methods: Two thousand, two hundred and forty-one laboratory request forms sent to the laboratory over a period of two months were assessed for their level of completeness. Results: Out of 2241 laboratory request forms, only 5 (0.2%) was fully completed. The most complete information on the forms included types of investigation required (98.9%), the gender of the patient (97.8%), the identity of consultant-in-charge of the patient (95.3%) and the referring physician's name and signature (93.8%). The least provided information was the time of collection of the specimen (0.7%). Conclusion: This study shows that laboratory request forms are frequently incompletely and inadequately completed. Continuous medical education of clinicians on the need for adequate completion of request forms is required.

Introduction: Histopathology Request Forms (HRFs) serve as interphase between clinicians and pathologists in making diagnosis of tissue pathology. Inadequacies of the completion of HRFs have been a source of major frictions between the two groups of physicians. Various reports have highlighted this inadequacy. The need for adequate information on the HRF to be standardized cannot be overemphasized. Aim: The paper aims to evaluate the histopathology request forms from institutions in Nigeria and to propose an improved prostate disease-specific histopathology request form. Methodology: Histopathological request forms from some major Nigerian health institutions were analyzed for adequacy based on required information for a standardized histological reportage. A request form specific for suspected prostate diseases was designed from the review of literature. Results: Histopathology request forms (HRFs) from sixteen Nigerian health institutions were received from all the geopolitical zones of the country following a request. All the HRFs were neither organ nor disease specific. None of the HRFs was adjudged to be satisfactory to produce enough information adequate for comprehensive histopathology reportage. A prostate disease-specific histological request form is proposed following review of literature. Discussion: The need for a comprehensive prostate-specific HRF cannot be overemphasized to improve the relationships between surgeons and pathologists and to improve reportage of prostate pathologies and the management of prostatic diseases. Conclusion: Adequate clinical information is needed for early and complete reportage of histopathological report of prostate diseases. [ABSTRACT FROM AUTHOR]

Context: The aim of this study is to evaluate the various determinants of the preanalytic phase of surgical pathology (SP) in Uyo. Materials and Methods: This is a cross-sectional descriptive study (prospective) of all SP specimens that were sent to the histopathology laboratory of University of Uyo Teaching Hospital, Uyo. A special pro forma/questionnaire was designed taking into account the various determinants of the preanalytic phase of SP. Results: The request form had the patients' name and sex in all cases reviewed. In all but 3%, the age was stated while the hospital number and site of biopsy or tissue were stated in 89% and 95%, respectively. Only 49% of cases had an adequate history. In majority of cases, the examination findings (63%) and previous investigations (83%) were not stated. The provisional diagnosis was indicated in 92% of cases while the requesting/managing clinicians' name was indicated in 94% of cases. Seventy percent of the request forms were written on behalf of the consultant by the resident doctors. The fixative was adequate in 92% of cases and all specimens came in formalin (though it was of different concentrations). Majority (92%) of the specimens came in plastic containers, which was adequate (large enough) for the size of the specimen. The provisional diagnosis was same with the histological diagnosis in 66% of cases. Conclusion: An adequately filled request form well labeled adequate specimen container containing the right amount of fixative will positively affect the preanalytic stage of SP.

Context: The aim of this study is to evaluate the various determinants of the preanalytic phase of surgical pathology (SP) in Uyo. Materials and Methods: This is a cross-sectional descriptive study (prospective) of all SP specimens that were sent to the histopathology laboratory of University of Uyo Teaching Hospital, Uyo. A special pro forma/questionnaire was designed taking into account the various determinants of the preanalytic phase of SP. Results: The request form had the patients' name and sex in all cases reviewed. In all but 3%, the age was stated while the hospital number and site of biopsy or tissue were stated in 89% and 95%, respectively. Only 49% of cases had an adequate history. In majority of cases, the examination findings (63%) and previous investigations (83%) were not stated. The provisional diagnosis was indicated in 92% of cases while the requesting/managing clinicians' name was indicated in 94% of cases. Seventy percent of the request forms were written on behalf of the consultant by the resident doctors. The fixative was adequate in 92% of cases and all specimens came in formalin (though it was of different concentrations). Majority (92%) of the specimens came in plastic containers, which was adequate (large enough) for the size of the specimen. The provisional diagnosis was same with the histological diagnosis in 66% of cases. Conclusion: An adequately filled request form well labeled adequate specimen container containing the right amount of fixative will positively affect the preanalytic stage of SP. [ABSTRACT FROM AUTHOR]

BACKGROUND AND AIM: Radiology request forms (RRFs) are clinical documents that state the patient's biodata, requisite investigation, justification for the investigation and identities of the referring clinician. The aim of the study is to determine the rate of inadequacy in completing the radiology request forms in order to create awareness on the import of the information on the medical request forms amongst the clinicians. METHODS: This was a descriptive study designed to measure the compliance of the referring clinicians in completing the radiology request forms. Radiology request forms were collected from the radiology department of the three largest public hospitals in our locality over five consecutive years and the rate of completion of each field in the request forms were analysed. RESULTS: The least completed field in the patients' biodata are patients' address, folder number, phone number and last menstrual period(LMP) which are 35%,19%, 10 and 50.6% respectively for hospital A, and 23%, 1%, 2.5% and11.5% for hospital B. Folder number and LMP were notenlisted in hospital C request forms. Clinical detail, date, patient's name and surname have the highest compltion rate in the three hospitals. Of the clinician's details, the resident/doctor's phone number is the least completed. CONCLUSION: There is general deficiency in adequate and complete filling of the request forms for radiological investigation in all the three major public hospital in our locality. Patient management should be seen as team work and all impediments should be removed to facilitate proper patient's management. [ABSTRACT FROM AUTHOR]

Communication is an essential element of good medical practice also in pathology. In contrast to technical or diagnostic skills, communication skills are not easy to define, teach, or assess. Rules almost do not exist. In this paper, which has a rather personal character and cannot be taken as a set of guidelines, important aspects of communication in pathology are explored. This includes what should be communicated to the pathologist on the pathology request form, communication between pathologists during internal (interpathologist) consultation, communication around frozen section diagnoses, modalities of communication of a final diagnosis, with whom and how critical and unexpected findings should be communicated, (in-)adequate routes of communication for pathology diagnoses, who will (or might) receive pathology reports, and what should be communicated and how in case of an error or a technical problem. An earlier more formal description of what the responsibilities are of a pathologist as communicator and as collaborator in a medical team is added in separate tables. The intention of the paper is to stimulate reflection and discussion rather than to formulate strict rules. [ABSTRACT FROM AUTHOR]

Objective The objective was to study radiologists’ experiences of written and oral communication with referring clinicians, and its potential implications for decision making and patient care. Methods Focus group discussions with 12 radiologists were carried out. Content analysis was used for interpretation of the data. Results Radiologists reported many problems with the request forms: improper choice of imaging examinations and procedures, insufficient patient history/information, unclear clinical questions, lack of specific terms and unclear abbreviations on the request form. Radiologists also mentioned other difficulties: insufficient attention among participating clinicians during conferences, difficulties in reaching the referring clinicians by telephone, and communication difficulties in making priorities between patients. To overcome these problems, radiologists suggested increased contacts between radiologists and clinicians, and educational activities. Conclusion A number of difficulties in oral and written communication were highlighted. The use of medical imaging may be optimized by joint discussions on indications and methodology and educational activities, such as lectures, seminars and conferences, directed to the medical community at large. Practice implications Improved communication between radiologists and referring clinicians should be encouraged to ensure diagnostic quality, correct patient prioritization and patient safety, and to avoid unnecessary delays and costs. [ABSTRACT FROM AUTHOR]

Background: The preanalytical phase is the most common source of laboratory errors. The goal of this descriptive study was to analyze the prevalence and type of preanalytical errors in relation to the site of sample collection (inpatient vs. outpatient) and the type of laboratory unit (hematology and coagulation vs. biochemistry). For the biochemistry unit, the data were also analyzed relative to the type of the analysis (stat vs. routine). Methods: We retrospectively analyzed the sample and test request form error rate for a 1-year period, from January to December 2008. Results: The frequency of the sample errors differed significantly between the emergency and routine biochemistry unit (0.69% vs. 2.14%; p<0.0001), and between inpatients and outpatients (1.12% vs. 1.36%; p=0.0006). Hemolysis was the most frequent sample error, accounting for 65% of all unsuitable specimens in the emergency biochemistry unit. The total sample error rate did not differ between hematology and coagulation vs. the biochemistry unit. The frequency of test request form errors differed significantly with respect to the sample collection site (p<0.0001), laboratory unit (p<0.0001) and type of the analysis (p<0.0001). Errors in the test request form were least frequent in the outpatient unit (2.98%) and most frequent in the routine biochemistry unit (65.94%). Conclusions: Sample and test request form errors in our laboratory are occurring with a frequency comparable to that reported by others. Continuous educational action is needed for all stakeholders involved in laboratory testing to improve the quality of the preanalytical phase of the total testing process. Clin Chem Lab Med 2010;48:1009–14. [ABSTRACT FROM AUTHOR]