Studying Patient Misidentifications in the Surgical Pathology: Identifying the Root Cause of a Rare but Major Defect
Frederick A Meier, Ruan C Varney, Richard J Zarbo. Henry Ford Health System, Detroit, MI
Background: A systematic approach to rare defects is a major challenge in surgical pathology continuous quality improvement. Patient misidentifications (patient misIDs) are infrequent but major defects in the surgical pathology process.
Design: We investigated the distribution throughout the entire surgical pathology testing process of defects that led to amended reports. Among 315 amendments in 2010, as we we processed 63,308 cases [5 amendments /1000 cases], 31 amendments were due to misidentifications [9.5 %], 8 to specimen defects [2.5 %], 16 to misinterpretations [5%], and 260 to report defects [83%] (Report defects were errors that did not involve misidentifications, specimen problems, or misinterpretations.) Of the 31 misidentifications, 6 were errors in determining laterality, 2 errors that designated the wrong tissue, and 1 error in designating location within a tissue. The remaining 22 misidentifications were of pateints. We specified the root cause for all of these 22 cases.
Results: Among more than 63,000 surgical specimens, 22 patient misIDs [3.5 misIDs/10,000 specimens] were indeed rare events. 13 (59%) occurred before arrival in the pathology department: 3 at patient registration (2 involving patient impersonation and 1 confusing mother and daughter), 10 at specimen collection: 5 skin biopsies in dermatologists' practices; 2 endometrial biopsies, one in a clinic, one in an emergency department; 2 placentas from two different labor and delivery units, and 1 transplant kidney biopsy from nephrology. Of the 9 patient misIDs in the pathology department, 3 skin biopsies, 3 liver biopsies, and 1 prostate case were confused at pathologist sign-out; 2 colon biopsies were confused at microtome sectioning.
Conclusions: Biopsies accounted for 16/22 (73%) and skin biopsies alone for 8/22 (36%) of all patient misIDs. The physical similarity of biopsies from different patients –at collection (8/10 cases) and at sign-out session (5/7 cases)- emerged as the main root cause. The same root cause also appeared for placentas confused at the point of colection and for GI biosies confused at microtome sectioning. Physical similarity lastly appears as the cause of confusion at specialty sign-out for standardized prostate resections. For the 19/22 patient misIDs that were not primary registration errors, failing to distinguish between grossly identical specimens was the root cause in all cases detected, both external and internal to the pathology department.
Category: Quality Assurance
Monday, March 19, 2012 1:00 PM
Poster Session II # 251, Monday Afternoon