[2113] Post-Analytical Phase Detection of Identification Errors in Anatomic Pathology

Matthew A Smith, Luke T Weihagen, N Paul Ohori. University of Pittsburgh Medical Center-Presbyterian, Pittsburgh, PA

Background: Identification errors in anatomic pathology may be related to misidentification of the patient, site, or procedure and can occur during any phase (pre-analytical [requisition], analytical [interpretation] and post-analytical [transmission of results]). When these errors are identified and corrected during the analytical phase, they constitute a “near-miss.” If they are identified afterwards, they are misses. Many groups now encourage a variety of processes to detect identification errors during the analytical phase. Nonetheless, some identification errors escape detection during the analytical phase and result in post-analytical errors which may have consequences. In this study, we investigate the details of post-analytical phase identification errors.
Design: Surgical pathology and cytopathology reports from 2008 to 2011 with subsequent amendments were identified. The reports and original requisitions were reviewed to classify the error by the subspecialty service involved, type of error, source of error, and the personnel involved in identifying the error.
Results: We identified 75 cases with subsequent amendments. The errors involved all anatomic pathology subspecialties (Table 1). The most frequent type of error was the “wrong anatomic site” provided on the requisition form (Table 2). The source of error was attributed to the submitting clinical staff in 59%, pathology department in 36%, and other sources in 5% of cases. Identification of the errors was made by clinicians in 60% of the cases, pathology department personnel in 34%, others in 6%.

Table 1. Number of errors in subspecialty services
ServiceNumber of Errors
Head and Neck Pathology10
Bone and Soft Tissue19
Consultation Service4

Table 2. Type and number of errors
Type of ErrorNumber of Errors
Wrong site by Pathology5
Wrong site on requisition32
Change in final diagnosis4
Specimen switch (same patient)4
Wrong pathology procedure4
Wrong procedure on requisition9
Identity issue1
Accessioned to wrong patient1

Conclusions: Post-analytical errors most frequently occurred due to inaccurate documentation (e.g. site). In daily practice, pathology department personnel may be limited in the means to verify the precise documentation of each specimen. Nonetheless, quality improvement may be accomplished by communicating and providing feedback to the clinical and pathology groups involved and focusing on the common types of errors.
Category: Quality Assurance

Monday, March 19, 2012 1:00 PM

Poster Session II # 250, Monday Afternoon


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