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Arch Pathol Lab Med. 2005 Apr;129(4):459-66.

Patient safety in anatomic pathology: measuring discrepancy frequencies and causes.

Author information

  • 1Department of Pathology, University of Pittsburgh, UPMC Shadyside Hospital, Pittsburgh, Pa 15232, USA. raabss@msx.upmc.edu

Abstract

CONTEXT:

Anatomic pathology discrepancy frequencies have not been rigorously studied.

OBJECTIVE:

To determine the frequency of anatomic pathology discrepancies and the causes of these discrepancies.

DESIGN:

Participants in the College of American Pathologists Q-Probes program self-reported the number of anatomic pathology discrepancies in their laboratories by prospectively performing secondary review (post-sign-out) of 100 surgical pathology or cytology specimens. Reasons for the secondary review included conferences, external review, internal quality assurance policy, and physician request.

PARTICIPANTS:

Seventy-four laboratories self-reported data.

MAIN OUTCOME MEASURES:

Frequency of anatomic pathology discrepancy; type of discrepancy (ie, change in margin status, change in diagnosis, change in patient information, or typographic error); effect of discrepancy on patient outcome (ie, no harm, near miss, or harm); and clarity of report.

RESULTS:

The mean and median laboratory discrepancy frequencies were 6.7% and 5.1%, respectively. Forty-eight percent of all discrepancies were due to a change within the same category of interpretation (eg, 1 tumor type was changed to another tumor type). Twenty-one percent of all discrepancies were due to a change across categories of interpretation (eg, a benign diagnosis was changed to a malignant diagnosis). Although the majority of discrepancies had no effect on patient care, 5.3% had a moderate or marked effect on patient care.Conclusions.-This study establishes a mean multi-institutional discrepancy frequency (related to secondary review) of 6.7%.

PMID:
15794667
[PubMed - indexed for MEDLINE]
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