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.

This survey-based study of primary care providers revealed a lack of standardization for the tracking, receiving, and reporting of laboratory results. Even practices with integrated electronic medical records reported the need for a back-up tracking system to ensure important test results are not lost.

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.

Delayed diagnosis from false-negative Papanicolaou (Pap) tests can have tragic results. This study re-screened liquid-based Pap tests of women who were later diagnosed with endometrial carcinoma. Of the 27 rescreened samples, 16 were recategorized to positive. Through root cause analysis, latent and active failures were identified, and several quality improvement initiatives were implemented.

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

This consensus statement provides an evidence-based definition of critical diagnoses and suggests that each institution create its own policy for how to manage communication of diagnoses.

Looking across 136 institutions, this study quantified mislabeling rates at a cumulative total of 0.11% for cases, specimens, blocks, and slides. The authors reinforce the need for quality monitoring since most errors were caught in the immediate steps following the error.

… 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.

This review addresses surgical specimen analysis errors and highlights tactics to improve the reliability of the process.

This AHRQ-funded study of cervical cancer screening results found a remarkably low incidence of missed malignancies. The authors analyzed Papanicolaou test results and the results of subsequent biopsies and found that the results were discordant in only 0.3% of cases, with most of these inconsistencies being clinically insignificant. Delayed diagnosis of cancer is a common cause of malpractice suits in ambulatory care. Although a prior study by Raab and colleagues found a higher overall error rate in anatomic pathology cancer diagnosis, this study documents that the US cervical cancer screening system appears to be very effective at preventing squamous cervical cancer. However, a systematic review of missed or delayed cancer diagnoses found that misdiagnosis of four common types of cancer—melanoma, as well as cancer of the breast, lung, or colon—remains common.

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.

This article provides guidelines for ensuring quality in surgical and autopsy pathology, including identifying and correcting errors.