[2073] Retrospective Blinded Review of Major Errors in Anatomic Pathology: Experience of a Tertiary Care Facility

Shweta Chaudhary, Leonard B Kahn, Tawfiqul Bhuiya. Hofstra-North Shore LIJ School of Medicine, Lake Success, NY

Background: Quality control and quality assurance are integral to the practice of Anatomic Pathology, a discipline in which it is difficult to define criteria's for evaluating these parameters. This study is focused on pathologist's interpretational diagnostic errors. We present a unique model of quality assurance in which the pathologists in the department perform a blinded review of major discrepancies which served to heightened awareness of patient consequences and reduce the number of errors.
Design: All types of errors including false positive/false negative and any error which was of clinical consequences were included in the study. The cases were blinded and given numeric designation. All pathologists were required to review the pertinent slides with the same information that was available to sign out pathologist. Based on the pathologist's consensus opinions, a final performance improvement report was generated. Impact on patient management was considered significant if error necessitated second surgery or an inappropriate surgery was performed because of incorrect diagnosis. Also, delayed treatment resulting from inappropriate diagnosis was considered as significant. If the diagnosis was corrected within short time frame and there was no change in management, the error was considered to be clinically insignificant.
Results: There were a total of 303 cases over the past 18 years. The cases were divided into various subspecialties and source of error (frozen section or permanent section) was noted.

Comparison of key features between two time periods

	1993-2001	2002-2010
Total errors	230/ 189515 (0.12%)	73/221112 (<0.01%)
Frozen interpretative errors	129	48
Errors on non frozen section cases	101	25
Significant patient consequences	31	15

Distribution of cases divided as per subspecialities

Subspeciality	cases no (%) [1993-2001]	cases no (%) [2002-2010]
Bone and Soft tissue	33 (14.4)	8 (10.9)
Neuropathology	19 (8.3)	4 (5.5)
Breast	36 (15.6)	14 (19.2)
GI	19 (8.3)	10 (13.7)
GU	20 (8.7)	5 (6.8)
GYN	38 (16.5)	11 (15.1)
Head & Neck	50 (21.7)	10 (13.7)
Thoracic and Pulm	15 (6.5)	11 (15.1)
Total	230	73

Conclusions: This study highlights the positive impact of systematic review in reducing pathologist's interpretational error and in identifying potential sources of error. Anonymous review process encourages active participation. To conclude, besides the routine quality control and assurance parameters, these cases can be used as an objective tool for monitoring professional competency and provides objective criteria for performance improvement for pathologists.
Category: Quality Assurance

Monday, March 19, 2012 2:00 PM

Platform Session: Section G, Monday Afternoon