[1859] An Audit of Surgical Pathology and Cytopathology Amended Reports over a 5 Year Period in a Tertiary Care Hospital.

Corwyn Rowsell, Michael Sidiropoulos, Zeina Ghorab, Mahmoud A Khalifa. Sunnybrook Health Sciences Centre, University of Toronto, ON, Canada

Background: Amended pathology reports (AmR) document changes in information that are made after a report is released. These may include changes in the diagnosis, comment, macroscopic and microscopic description, clinical information, and patient identification. We performed an audit of AmR over a 5 year period focussing on total AmR rates and types of changes in order to identify areas for quality improvement.
Design: Analysis of AmR in surgical pathology and cytopathology for the calendar years 2005-2010 at Sunnybrook Health Sciences Centre was performed. AmR were collated for each quarter (Q) of the year and the following parameters were recorded as a percentage per total cases signed out: total AmR and AmR by type of change (changes in diagnosis comment, macroscopic description, microscopic description, clinical information, patient identification).
Results: A total of 937 surgical pathology and 141 cytopathology AmR were reviewed over the 5 year period. Total AmR cases reviewed and AmR rates per total accessions are listed in Table 1. Surgical pathology AmR due to corrections in clinical information (0.22% in Q1 2005, 0.07% in Q2 2010) and cytopathology AmR due to changes in diagnosis/comment (0.07% Q1 2005, 0.01% Q2 2010) both showed a downward trend from 2005 to 2010, but otherwise no significant changes or trends were seen over the study period.

Table 1.
 Total AmRTotal AmR %Change diagnosis/comment %Change micro %Change macro %Correct clinical info %Correct patient ID %
Surgical pathology9370.57 (range 0.27-0.93)0.26 (range 0.13-0.43)0.04 (range 0-0.07)0.09 (range 0-0.23)0.16 (range 0.07-0.48)0.015 (range 0-0.05)
Cytopathology1410.09 (range 0.01-0.18)0.046 (range 0-0.08)0.001 (range 0-0.01)0.014 (range 0-0.08)0.018 (range 0-0.05)0.006 (range 0-0.03)



Conclusions: Changes in diagnosis/comment are the most common type of amendment for both surgical pathology and cytopathology reports in our department. Future quality assurance initiatives should focus on the reasons for these changes and the clinical impact of the change in diagnosis. Patient ID corrections were relatively rare, but due to the potentially dire consequences of such errors, new workflow solutions have been introduced to attempt to reduce or eliminate such errors.
Category: Quality Assurance

Monday, February 28, 2011 1:00 PM

Poster Session II # 214, Monday Afternoon

 

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