Adequacy of clinical information in anatomical pathology requests in a tertiary hospital

Abstract

Background: Absent or inadequate clinical history on pathology request forms contributes to pre-analytical errors that might affect patient safety. Aims: To audit the adequacy of clinical history on histopathology request forms and analyse the effectiveness of a targeted intervention to improve clinical history provision. Methods: This was an interventional, single-centre study over 6 months. A mandatory field was created where the reporting pathologist scored the history provided as either adequate or non-adequate (absent, inadequate or misleading clinical history). Inadequate history was defined as the requirement for additional information before a diagnosis could be rendered. Data was collected monthly. After 2 months the data was provided to individual clinicians from two outlier departments with an explanation of the audit. Chi-squared analysis was used to compare adequacy before and after the intervention. Results: 12,728 request forms were reviewed; 848 (6.7%) were non-adequate forms [of these 361 (43%) were inadequate or misleading and 487 (57%) had no clinical history]. Two departments had 109 (25%) non-adequate requests prior to the intervention; after the intervention, 47 (8.4%) were non-adequate (p≤0.001). Conclusions: A simple audit and targeted intervention can significantly improve the adequacy of clinical information in anatomical pathology request forms to improve patient safety.