AP Discrepancy Rates - College of American Pathologists

Genital, female
Breast
Lung
Genital, male
Soft tissue
Lymph node
Hepatobiliary
Urinary tract
Pharynx
Endocrine
Bone marrow
Bone
Neuropathology
Kidney
Pancreas
Organ Clear, %
Salivary gland
Spleen
Gastrointestinal and other
Table 6. Clarity of Report by Organ Type
97.6
96.5
97.0
98.6
97.7
97.6
96.6
98.3
98.6
99.2
94.4
99.0
95.4
96.2
96.8
100.0
90.9
97.4
Mildly
Unclear, %
Moderately
Unclear, %
Markedly
Unclear, %
Total 97.4 2.3 0.3 0.07
Table 7. Discrepancy Type, the Original and Review
Diagnoses for Categoric Discrepancies, and the Effect
of Discrepancy on Patient Outcome
Discrepancy type
Change within same category
Change in categoric interpretation
Typographic error
Change in patient information
Change in margin status
Original interpretation for categoric
discrepancies
Benign
Atypical
Suspicious
Malignant
Reviewed interpretation for categoric
discrepancies
Benign
Atypical
Suspicious
Malignant
Effect on patient outcome
Harm
Marked
Moderate
Mild
Near miss
No harm
Specimens, No. (%)
415
194
85
75
37
15
25
27
16
16
28
21
7
28
63
8
12
43
33
283
(100)
(47.8)
(20.9)
(18.5)
(9.1)
(3.7)
(29.8)
(32.1)
(16.0)
(16.0)
(33.3)
(25.9)
(8.3)
(33.3)
(16.6)
(2.1)
(3.2)
(11.3)
(8.7)
(74.7)
sons for review. If a near-miss event occurred, the reason
for case review was more likely to be extradepartmental
review compared with all other reasons for review.
Table 9 shows that the reason for case review correlated
with patient outcome in discrepant cases (P .02). Harm
occurred more frequently in discrepant cases that were
reviewed at the request of a clinician (23.5%) and interdepartmental
conference (25.0%). Clinician-directed review
was the most common method that detected a discrepancy
(23.0% of all cases reviewed). The majority of
discrepant cases detected at an intradepartmental conference
were associated with no-harm events.
Arch Pathol Lab Med—Vol 129, April 2005 Patient Safety in Anatomic Pathology—Raab et al 463
1.9
2.1
2.8
1.4
2.1
2.4
3.4
1.7
1.4
0.8
3.8
1.0
4.6
3.8
3.2
0
9.1
2.4
0.3
1.3
0.2
0
0
0
0
0
0
0
1.9
0
0
0
0
0
0
0.2
0.2
0.1
0
0
Of the 74 institutions, the number that had a conference
devoted to breast review was 33; chest, 21; endocrine, 8;
gastrointestinal, 22; general surgical, 29; genitourinary
tract, 18; gynecologic, 26; head and neck, 16; hematopathology,
20; liver, 15; renal, 18; and tumor board, 60. Institutional
quality assurance practices were measured as
well: 52 institutions had an intradepartmental conference
for difficult cases; 31 reviewed a percentage of cases after
sign-out; 22 reviewed all malignancies before sign-out; 19
reviewed a percentage of cases before sign-out; 6 reviewed
all malignancies after sign-out; and 1 reviewed all cases
before sign-out. Of the institutions that made changes to
the reports after an error, 43 issued an amended report
and did not retrieve the original report; 3 retrieved the
original report, stamped it ‘‘in error,’’ and filed the report
in the chart; 3 destroyed the original reports; and 3 handled
the change using other methods.
COMMENT
This is the first study to determine a baseline anatomic
pathology discrepancy frequency across multiple pathology
laboratories. Based on secondary pathologist review,
the mean anatomic pathology discrepancy frequency
(based on cases reviewed through several different methods)
was 6.7%, and the variability across laboratories was
striking, with the 25th and 75th percentiles being 10.0%
and 1.0%, respectively.
Discrepancy represents one form of error, and based on
literature review of a number of error-detection methods,
Raab 2 estimated that the mean laboratory error frequency
ranged from 1% to 5%. The discrepancy frequency established
in this Q-Probes study is based on review of selected
cases (a targeted group of cases studied), a bias that
may overestimate overall laboratory error. Error frequencies
partly depend on the method of case detection, and
the more thoroughly one looks for error, the more frequently
one will find it. 1,29 As expected, some of the secondary
review methods used in this study detected more
error than other methods; for example, clinician-directed
review detected a discrepancy (23.0% of cases) more frequently
than random review (4.3%). In general, methods
0.3
0
0
0
0
0
0
0
0
0
0
0
0
0