Amended Report Worksheets in Surgical Pathology
C Bernadt, CS Jensen, SS Raab, JA Weydert. University of Iowa, Iowa City, IA; University of Colorado Denver, Denver, CO
Background: Amended reports represent a valuable resource for identifying and tracking deficiencies in the practice of surgical pathology. An amended report worksheet is a form that can be completed by the pathologist and allows the pathologist to document the discoverer of the error/deficiency, the mechanism of discovery, the error/deficiency type, and the type of revision made to the original report. We performed an audit of one year's worth of amended report worksheets in order to determine: 1) if pathologists were compliant with this tracking tool and; 2) if useful data could be obtained for the purposes of quality improvement in surgical pathology.
Design: Retrospective analysis of the amended report worksheets in general surgical pathology for the calendar year of 2007 at the University of Iowa Hospitals and Clinics. In addition, there was review of clinical records of all cases in which the amended report changed either the primary or secondary diagnostic characteristics to assess the clinical impact of such changes.
Results: A total of 170 amended reports were issued in general surgical pathology in 2007. Of these, amended report worksheets were completed for 151 cases (89% pathologist compliance). Clinician initiated review of a case was the most often marked mechanism of error discovery (35.5%). Defective reports, which includes erroneous and missing non-diagnostic information and errors in dictation and/or typing was the most common deficiency type (52%), which corresponded with editorial changes that do not change primary or secondary diagnostic information as the most common type of revision (78%). Revisions that changed either primary or secondary diagnostic information accounted for only 7.2% and 13.2% of amended reports, respectively. The most common types of deficiency in amended reports with revisions to either primary or secondary diagnostic information were interpretive errors (40%), followed by defective reports (31.4%) and inadequate specimen handling (20%). Review of clinical records of all cases that had revisions to either primary or secondary diagnostic information did not reveal any negative impact on clinical outcome.
Conclusions: Amended report worksheets appear to provide an easy and convenient mechanism of compiling categorical quality data related to amended reporting in surgical pathology. This type of data can be of use in targeting recurrent or over-represented deficiencies in surgical pathology reporting, and can serve as a bench mark for quality improvement programs.
Category: Quality Assurance
Monday, March 9, 2009 9:30 AM
Poster Session I Stowell-Orbison/Autopsy Award # 235, Monday Morning