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National anatomic pathology errors database can reduce hospital pathology errors

Pathology errors made on tissue specimens from patients can affect patient diagnosis and treatment. To find out how often pathology errors occur and with what types of tissues, and to decrease the clinical impact of these errors, the Agency for Healthcare Research and Quality funded a national anatomic pathology errors database in 2002 (HS13321). The database tracks more frequent pathology errors and those that result in serious harm in order to design quality improvement interventions to reduce such errors.

In the first year of funding, four institutions, the University of Pittsburgh, Henry Ford Hospital, University of Iowa, and Western Pennsylvania Hospital, reported cell-tissue correlation error data, that is, when there was a discrepancy between cell and tissue pathology reports of the same anatomic tissue. They performed root cause analysis to determine the source of error and implemented error reduction plans.

The correlation error frequency ranged from 0.17 percent to 0.63 percent for patients who had both a Pap test (of cervical cells) and a procedure that generated tissue samples (for example, cervical or vaginal biopsy, cone biopsy, or hysterectomy).

The lungs (ranging from 16.5 percent to 62.3 percent of all pathology errors) and bladder (ranging from 4.4 to 25 percent of all pathology errors) were the anatomical sites with the most nongynecologic pathology errors. They were also the sites that had the most frequent discrepancy between cell and tissue pathology reports (for example, a diagnosis of atypical cells made on a bronchial washing specimen and a diagnosis of non-small-cell carcinoma made on a bronchial biopsy specimen). Thus, the participating sites developed plans to specifically reduce pulmonary and urinary bladder pathology errors, for example, double-viewing of all bronchial washing and brushing specimens to decrease the number of specimen interpretive errors. Other plans were aimed at problems with the specimen sampling process.

More details are available in "Anatomic pathology databases and patient safety," by Stephen S. Raab, M.D., Dana M. Grzybicki, M.D., Ph.D., Richard J. Zabo, M.D., D.M.D., and others, in the October 2005 Archives of Pathology and Laboratory Medicine 129, pp. 1246-1251.

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