[2030] Surgical Pathology Report Defects: A Q-Probes Study of 73 Institutions

Keith E Volmar, Michael O Idowu, Jennifer L Hunt, Frederick A Meier, Raouf E Nakhleh. Rex Pathology Associates, Raleigh, NC; Virginia Commonwealth University, Richmond, VA; University of Arkansas for Medical Sciences, Little Rock, AR; Henry Ford Hospital, Detroit, MI; Mayo Clinic, Jacksonville, FL

Background: The rate of surgical pathology report defects is an indicator of quality and it affects clinician satisfaction. This study aimed to establish benchmarks for defect rates and defect fractions and to identify practice characteristics that may influence those rates.
Design: Participants in a 2011 Q-Probes quality improvement program of the College of American Pathologists were asked to prospectively review all surgical pathology reports that underwent changes to correct various defects. Cases were collected for three months or until 50 reports were identified. Details regarding the defects were reported.
Results: 73 institutions reported on 1,688 report defects discovered in 360,218 accessioned cases, for an overall defect rate of 4.7 per 1,000 cases. Institutional defect rates are provided in the table below.

Institutional Rates of Surgical Pathology Report Defects
Defects per 1,000 cases13.

Of the reports with defects, the distribution of defect type was as follows: 14.6% misinterpretations, 13.3% misidentifications, 13.7% specimen defects, 58.4% other defects. Overall, defects were most often detected by pathologists (47.4%), followed by clinicians (22.0%), but there were differences in who discovered various defect types. Specifically, compared to other personnel, pathologists more often detected misinterpretations (73.5%, P<.001) and specimen defects (82.7%, P<.001), while misidentifications were most often discovered by clinicians (44.6%, P<.001). Significantly higher defect rates were seen in institutions with a pathology training program (8.5 vs 5.0 per 1,000, P=.01). A lower rate of misidentification was seen when all malignancies were reviewed by a second pathologist before sign out (0.0 vs 0.6 per 1,000, P<.001), and a lower rate of defects from specimen issues was seen with intradepartmental review of difficult cases after sign out (0.0 vs 0.4 per 1,000, P=.02). Institutions that review a set percentage of cases after sign out tended to have higher defect rates (median 6.7 vs 3.8 per 1,000, P=.10).
Conclusions: This study provides benchmarking data on report defects and defect fractions. The study reveals a higher rate of report defects and a higher fraction of misinterpretations than prior studies.
Category: Quality Assurance

Tuesday, March 5, 2013 9:30 AM

Poster Session III # 259, Tuesday Morning


Close Window