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.
|Total AmR||Total AmR %||Change diagnosis/comment %||Change micro %||Change macro %||Correct clinical info %||Correct patient ID %|
|Surgical pathology||937||0.57 (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)|
|Cytopathology||141||0.09 (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)|