Misinterpretation of test results can have harmful consequences for patients. This guideline synthesized the literature on surgical pathology and cytology case reviews to determine recommendations to improve diagnostic accuracy, such as involving anatomic pathologists in developing procedures to detect disagreements and errors, conducting case reviews in a timely fashion, and continuously tracking and documenting case review findings.

… lost. … West DR, James KA, Fernald DH, Zelie C, Smith ML, Raab SS. Laboratory medicine handoff gaps experienced by …

This commentary illustrates the process of decision-making in pathology to reveal factors contributing to disagreements in interpretation of test results. Emphasizing how differences between slow thinking and fast thinking can cause interpretation errors, the author recommends system-level approaches and team-based solutions, respectively, to improve safety in pathology.

Entering pathology test results into the wrong patient’s record but discovering the error before the results are released is a type of pathology near miss. Using Lean quality improvement program (LQIP), including culture change, one anatomic pathology laboratory sought to reduce both process- and operator-dependent near-miss events. The laboratory was able to decrease the frequency of process-dependent near-miss events, though not the operator-dependent events. The authors cite lack of leadership buy-in as a major challenge.  

Diagnostic error in pathology can result in delayed treatment or initiation of incorrect treatment. Peer review, or second opinion, is used by many laboratories to improve diagnostic accuracy and precision. This paper describes the use of Lean A3 method to identify and reduce root causes of cognitive and latent errors in pathology misdiagnosis.

… initiatives were implemented. … Sams SB,  Currens HS, Raab SS. Liquid-based Papanicolaou tests in endometrial …

This study used root cause analysis to identify latent factors that contributed to near misses in processing surgical pathology specimens.

… calls for improvements to prevent diagnostic errors . … Raab SS, Grzybicki DM. CA Cancer J Clin. 2010;60:139-165.   …

This study found that a focused review process detects a higher proportion of surgical pathology errors than a targeted random review process.

Laboratories with ongoing quality monitoring programs had a lower incidence of specimen labeling errors, as did institutions that provided around-the-clock phlebotomy services.

Lean methodology is a quality improvement method to increase safety and efficiency in healthcare. In this small study, five clinicians in a gynecology practice used Lean methods to redesign the workflow to improve the diagnostic accuracy of Pap tests. Although two clinicians dropped out of the study, the remaining three improved Pap test quality and diagnostic accuracy, maintained up to six months.

… suits in ambulatory care. Although a prior study by Raab and colleagues found a higher overall error rate in …

This study summarizes the findings from three root cause analyses to highlight the challenges in preventing patient identification errors in surgical pathology specimens. The authors suggest the use of a time-out strategy that would reduce the risk of the wrong patient receiving radiation or surgical therapy.

The authors compared the frequency of diagnostic error for a thyroid aspiration service before and after applying error reduction strategies. They found the changes led to significant improvements.

The investigators analyzed information on misidentified laboratory specimens and found that such errors are common. Most errors are detected prior to results being communicated and are rarely associated with adverse patient incidents.

… pathologist reluctance to change or challenge a peer's reading is a contributing factor. …

This AHRQ–funded study used root cause analysis to explore errors in a specific diagnostic procedure. They identified failure modes and developed an improvement initiative to enhance the accuracy of the process.

This study demonstrated improved outcomes with implementation of an office redesign in workflow based on Toyota production systems methods.

This AHRQ-funded study estimated a 12% error rate in cancer diagnosis based on discrepant evaluation of two specimens from the same organ. Investigators compiled web-based pathologic data from four institutions and created a standardized system to establish correlation error frequencies between cytologic and histologic samples during a 6-month period (eg, bronchial washings and a lung biopsy). Findings suggested that error rates were dependent on the institution and an association existed between the institution and error cause, but agreement was lacking on whether these errors resulted from misinterpretation or poor clinical sampling. Disagreement also existed on the clinical significance of the errors, an issue that results from an undeveloped taxonomy in this arena. While a previous systematic review used autopsy findings to report on clinically significant errors, this study builds on that literature by employing a method that is not limited by the overall low rate of autopsies performed nationally.