Amended Report Resulting From an Interpretation Error

Abstract

Amended reports may result from preanalytical, analytical, or postanalytical error types. We report the case of a patient, a 63-year-old man, who presented with hematuria and cystoscopy, which revealed a bladder mass. A biopsy was done at an outside institution. Subsequently, the patient was referred to our institution and another biopsy was done. The pathologist who reviewed this second biopsy did not review the first biopsy and had no knowledge of a prior biopsy. The pathologic findings reported in the second biopsy were benign with “extensive intestinal metaplasia of urothelial mucosa.” This case was subsequently reviewed by another pathologist at our institution, which resulted in an amended report indicating that the urinary bladder showed an in situ and invasive high-grade urothelial carcinoma with invasion of the detrusor muscle and focal extension of the carcinoma into perivesical adipose tissue. The original first biopsy was also reviewed later and showed that there was high-grade urothelial carcinoma. The patient underwent a radical cystoprostatectomy, which showed extensive disease with metastatic carcinoma in lymph nodes. Although this case only resulted in a short delay in diagnosis with subsequent appropriate patient management, it illustrates an example of an interpretation or analytical error in surgical pathology, which affected patient care. Effective communication, adequate history, and examination of prior surgical pathology material might have helped in avoidance of the misdiagnosis. Errors such as this may have been missed and only discovered much later, resulting in increased morbidity and mortality. An analysis of error types within amended reports may provide pivotal strategies in error reduction.