[1847] Misidentifications as Root Causes for Amended Reports in Surgical Pathology.

Frederick A Meier, Ruan C Varney, Cheryl Neuman, Adrian Ormsby, Osama Alassi, Richard J Zarbo. Henry Ford Hospital, Detroit, MI

Background: During 2008-2009 we used a previously validated taxonomy of defects (misclassifications, specimen defects, misinterpretations, report defects) to identify causes of amendments in surgical pathology reports. This study assess the contribution of misidentifications (mis-Ids) to amendments and sorts through their root causes.
Design: For the two year period, amendments were classified as they occurred, measured as defects per thousand cases, and placed into the four categories. For the category of mis-Ids, defects were sub-classified as patient, anatomic site, laterality, and tissue type mis-Ids. Among the patient mis-Ids, the loci of misidentification events were further determined to be external (outside the pathology department) vs. internal (inside the pathology department).
Results: 512 amendments were classified as they occurred among 92,509 accessions (5.5 defects/1000 accessions): 12% (62/512) were mis-Ids, 4.7% (24/512) specimen defects, 4.5% (23/512) mis-interpretations, and the remaining 79% (403/512) report defects not qualifying for the previous three categories. Among mis-Ids, 47% (29/62) were of patients, 8% (6/62) of anatomic site, 32% (20/62) of laterality, and 11% (7/62) of tissue type. 38% (11/29) of patient mis-Ids occurred internally – in the pathology department.
Conclusions: During a two year span with a stable defect rate of 5.5 report defects/1000 accessions, mis-Ids accounted for 12% of all amendments; patient mis-Ids accounted for almost half (47%) of all mis-Ids; more than a third (38%) of patient mis-Ids occurred within the pathology department's control. To the extent that mis-Ids lead to amended reports, these three characteristics – the fraction of all amendments caused by mis-Ids, the fraction of all mis-Ids that are patient mis-Ids, and the fraction of patient mis-Ids that occur internally – quantify salient effects of mis-identifcation in the surgical pathology diagnostic process.
Category: Quality Assurance

Monday, February 28, 2011 1:00 PM

Poster Session II # 203, Monday Afternoon


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