[2011] Discrepancies between Intraoperative Consultations and Final Pathology Report: Root Cause Analysis as a Means for Performance Improvement

Sharon B Sams, Joshua A Wisell. University of Colorado School of Medicine, Aurora, CO

Background: Discrepancies between intraoperative consultation with frozen section diagnosis and the final pathology report potentially alter surgical decisions and impacts patient care. Our goal was to use root cause analysis to identify the source of discrepancy and guide performance improvement initiatives.
Design: A retrospective review of intraoperative consultations (n= 1042) performed at a tertiary level hospital and cancer center over a six month period was performed to identify deferrals and discrepancies between the intraoperative consult report and the final pathology report. Using a modified Eindhoven classification method we identified the process errors and cognitive errors leading to discrepant results.
Results: A total of 50 (4.8%) discrepancies and 24 (2.3%) deferrals were identified and in all cases, no major clinical harm was identified. Process errors (n=28, 56%) were subdivided into gross sampling (n= 16, 32%) histologic sampling (n=8, 16%) and surgical sampling (n=2, 4%). Interpretation errors (n=22, 44%) included under-calls/ false negative (n=8, 16%) over-calls/false positive (n=10, 20%) and misclassification errors (n=4, 8%).


Conclusions: The majority of discrepancies (96%) occurred during gross room processing or interpretation and only small percentage were pre-analytic (due to surgical sampling). In our limited study, the area for greatest improvement would be directed towards gross sampling of specimens followed by a standardized approach to frozen section histology. Interpretation errors may be secondary to heuristic bias or educational limitiations. We conclude that analysis of the etiology of discrepancies can be a useful tool to identify areas for performance improvement.
Category: Quality Assurance

Tuesday, March 5, 2013 9:30 AM

Poster Session III # 264, Tuesday Morning

 

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