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The Landscape of Error in Surgical Pathology

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Error Reduction and Prevention in Surgical Pathology

Abstract

In this chapter, we examine the landscape of error in surgical pathology. We begin with definitions of error and related terms.

Process errors are found by root cause analysis of surgical amendments. They fit Charles Perrow’s definition of normal accidents: they are untoward consequences of concentration, complexity, and tight couplings of steps within an information-driven production system. Electronic information transfer plays an ambiguous role in the system: it both engenders defects and facilitates counter measures.

In any flow of information, all attempts at communication entail cognitive errors. Among them are interpretative errors, our focus in surgical pathology. Many factors contribute to interpretative errors: variable validity, reproducibility, detail of interpretations, extensions from particular findings to general diagnoses, variation in classifications, and changing evidence bases for histopathologic diagnosis.

Analysis of amendments has produced a consistent classification of surgical pathology production process errors: misidentifications, specimen defects, misinterpretations, and report defects. Currently, the surgical pathology report production process is a “three sigma” system; it averages 5-amendments per 1000 issued reports; misidentifications and misinterpretations, particularly confusing errors, both cause between 0.5 and 1 defect per 1000 reports.

Review of surgical pathology cases consistently produces discrepancies. These differences between primary and review diagnoses depend on characteristics of the review event: internal vs. external reviews, unfocused vs. focused reviews, and reviews across different diagnostic domains.

Specific studies suggest that reviews of relatively small numbers of cases may leverage reduction of much larger fractions of amendments and that focused reviews systematically detect more discrepancies than reviews of set percentages of cases.

Surgical pathologists do well both to monitor process errors, to find and eliminate their root causes, and to review interpretive discrepancies, factoring in their relative likelihoods in different diagnostic situations.

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Authors and Affiliations

  1. Department of Pathology and Laboratory Medicine, Henry Ford Hospital, 2799 West Grand Blvd, 48202, Detroit, MI, USA

    Frederick A. Meier MD, CM

  2. Department of Pathology, School of Medicine, Wayne State University, 48202, Detroit, MI, USA

    Frederick A. Meier MD, CM

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  1. Pathology, Mayo Clinic Jacksonville, Jacksonville, Florida, USA

    Raouf E. Nakhleh

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Meier, F. (2015). The Landscape of Error in Surgical Pathology. In: Nakhleh, R. (eds) Error Reduction and Prevention in Surgical Pathology. Springer, New York, NY. https://doi.org/10.1007/978-1-4939-2339-7_2

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