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.
|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|
|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)|