Do Amended Reports Get to Where They Should?
B Arcarese, P Cohen, L Hao, M Pinto, V Parkash. Yale University School of Medicine, New Haven, CT
Background: Amended pathology reports (AmR) are issued to correct erroneous information. To avoid improper treatment based on the original incorrect report, the AmR needs to reach, and come to the attention of, the treating physician (phyT). However, the physician of record (phyR) is often not the phyT. Frequently, especially in cases with malignant diagnoses, the phyR is a radiologist or a surgeon who performed the biopsy or surgery, and the phyT is an oncologist or radiation therapist. Pathology offices typically send AmR to the phyR, and do not have measures in place to ensure that a copy of the corrected report gets to the phyT.
Design: All AmR with a change in the final diagnosis field of the report, and were issued >21 days after the original signout, were tracked. A chart review to determine receipt of AmR was performed in the phyR's office. The phyT was identified, and a similar chart review was done at the phyT's office. Both sets of physicians were asked to answer a short questionnaire.
Results: Of a total of 194 AmR over an 18 month period, 60 reports were amended due to changes in the final diagnosis field. Of these, 21 were amended 21 days or more after sign-out with a range of 3 weeks to 4 months. Of these, 16 pertained to malignant diagnoses - including 7 breast, 4 hematopathology, 2 gynecologic, and 1 each pulmonary, soft tissue and genitourinary cases. The phyT was the phyR (either as a primary or secondary clinician) in 9 cases. The remaining 7 had only the phyR listed in the pathology files. 5 of these had an AmR in the chart of the phyR. ONLY 1 had an AmR in the phyT chart. The phyR questionnaire revealed that, in general, phyR submitted AmR to the phyT if the AmR was received prior to the patient's referral to the phyT, but did not necessarily send it along if the AmR was received after the patients referral. Fortunately, only 1 case had a major amendment (a negative to positive lymph node (N0 to N1(mic)), and although this case did not have an AmR in the chart, the corrected stage was entered in the chart based on a discussion at Tumor Board. The phyT questionnaire revealed that failing to receive the AmR was not rare, but in general, major changes were communicated via Tumor Board conferences or other mechanisms.
Conclusions: An understanding of error-prone steps in a system is fundamental to achieving a planned and organized system for error reduction. We have identified an error prone step in the AmR transmission system that needs to be addressed.
Category: Quality Assurance
Tuesday, March 10, 2009 8:00 AM
Platform Session: Section F 1, Tuesday Morning