Routine Review of Surgical Pathology Cases as a Method by Which to Reduce Diagnostic Errors in a Community Hospital

Abstract

When surgical pathology reports are discovered to contain errors after those reports have been released to clinicians, it is common practice for pathologists to correct and reissue them as “amended” reports. Measuring the rates with which surgical pathology reports are amended is a convenient quality assurance tool by which to gauge the frequencies of errors occurring in surgical pathology reporting. The purpose of this study was to determine whether routine review of surgical pathology case material before the release of surgical pathology reports would lower the rate with which surgical pathology reports were amended to correct misdiagnoses. In the yearlong periods before and after institution of this intervention, the annual rates of amended reports issued for the purpose of correcting misdiagnoses were 1.3 per 1000 cases and 0.6 per 1000 cases, respectively.