Improving patient safety by examining pathology errors

Clinics in Laboratory Medicine

Volumn 24, Issue 4, 2004, Pages 849-863

  Raab, Stephen S ^a  

^a UNIVERSITY OF PITTSBURGH MEDICAL CENTER   (United States)

Author keywords

[No Author keywords available]

Indexed keywords

CANCER DIAGNOSIS; CLINICAL EXAMINATION; CORRELATION ANALYSIS; CYTOLOGY; DATA BASE; DIAGNOSTIC ERROR; HUMAN; MEDICAL ERROR; PATIENT CARE; PRIORITY JOURNAL; QUANTITATIVE ANALYSIS; REVIEW; SAFETY;

DIAGNOSTIC ERRORS; HUMANS; PATHOLOGY, SURGICAL; PATIENTS; SAFETY MANAGEMENT;

EID: 9144259753     PISSN: 02722712     EISSN: None     Source Type: Journal    
DOI: 10.1016/j.cll.2004.05.014     Document Type: Review

References (87)

1. L.T. Kohn J.M. Corrigan M.S. Donaldson To err is human: building a safer health system 1999 National Academy Press Washington, DC
2. E.C. Becher, and M.R. Chassin Improving the quality of health care: who will lead? Health Aff (Millwood) 20 2001 164 179
3. J.P.A. Ioannidis, and J. Lau Evidence on interventions to reduce medical errors. An overview and recommendations for future research J Gen Intern Med 16 2001 325 334
4. Joint Commission on Accreditation of Healthcare Organizations Sentinel events: approaches to error reduction and prevention J Qual Improv 24 1998 175 186
5. K.W. Kizer Patient safety: a call to action: a consensus statement from the national quality forum MedGenMed 3 2001 10
6. G. Meyer, N. Foater, S. Christrup, and J. Eisenberg Setting a research agenda for medical errors and patient safety Health Services Res 2001 36
7. G. Meyer, D.I. Lewin, and J.M. Eisenberg To err is preventable: medical errors and academic medicine Am J Med 110 2001 597 603
8. L.L. Leape, A.I. Kabcenell, T.K. Gandhi, P. Carver, T.W. Nolan, and D.M. Berwick Reducing adverse drug events: lessons from a breakthrough series collaborative Jt Comm J Qual Improv 26 2000 321 331
9. M.P. Silver, and J.A. Antonow Reducing medication errors in hospitals: a peer review organization collaboration Jt Comm J Qual Improv 26 2000 332 340
10. L.S. Stump Re-engineering the medication error-reporting process: removing the blame and improving the system Am J Health Syst Pharm 57 Suppl 4 2000 S10 S17
11. N.S. Goldstein Diagnostic errors in surgical pathology Clin Lab Med 19 1999 743 756
12. R.J. Zarbo Monitoring anatomic pathology practice through quality assurance measures Clin Lab Med 19 1999 713 742
13. A.D. Ramsay Errors in histopathology reporting: detection and avoidance Histopathology 34 1999 481 490
14. G.K. Hahm, T.H. Niemann, J.G. Lucas, and W.L. Frankel The value of second opinion in gastrointestinal and liver pathology Arch Pathol Lab Med 125 2001 736 739
15. R.E. Safrin, and C.J. Bark Surgical pathology signout. Routine review of every case by a second pathologist Am J Surg Pathol 17 1993 1190 1192
16. I.A. Cree, W. Guthrie, J.M. Anderson, M.P. Holley, D. Hopwood, and D.S. Sanders Departmental audit in histopathology Pathol Res Pract 189 1993 453 457
17. G.R. Hocking, N. Niteckis, B.J. Cairns, and J.A. Hayman Departmental audit in surgical anatomical pathology Pathology 29 1997 418 421
18. A.D. Ramsay, and P.J. Gallagher Local audit of surgical pathology. 18 months' experience of peer-review-based quality assessment in an English teaching hospital Am J Surg Pathol 16 1992 476 482
19. M.E. Whitehead, J.E. Fitzwater, S.K. Lindley, S.B. Kern, R.C. Ulirsch, and W.F. Winecoff III Quality assurance of histopathologic diagnoses: a prospective audit of three thousand cases Am J Clin Pathol 81 1984 487 491
20. M.E. Whitehead, J.H.K. Grieve, M.J. Payne, and M.S. Ross Quality assurance of histopathologic diagnosis in the British Army: role of the Army Histopathology Registry in completed case review J R Army Med Corps 132 1986 71 75
21. J.A. Zuk, W.E. Kenyon, and M.W. Myskow Audit in histopathology: description of an internal quality assessment scheme with analysis of preliminary results J Clin Pathol 44 1991 10 15
22. A.C. Lind, C. Bewtra, J.C. Healy, and K.L. Sims Prospective peer review in surgical pathology Am J Clin Pathol 104 1995 560 566
23. Y.M. Chan, A.N. Cheung, D.K. Cheng, T.Y. Ng, H.Y. Ngan, and L.C. Wong Pathology slide review in gynecologic oncology: routine or selective? Gynecol Oncol 75 1999 267 271
24. W.M. Murphy, I. Rivera-Ramirez, L.G. Luciani, and Z. Wajsman Second opinion of anatomical pathology: a complex issue not easily reduced to matters of right and wrong J Urol 165 2001 1957 1959
25. J.C. Wurzer, T.I. Al-Saleem, A.L. Hanlon, G.M. Freedman, A. Patchefsky, and G.E. Hanks Histopathologic review of prostate biopsies from patients referred to a comprehensive cancer center Cancer 83 1998 753 759
26. K.M. Clary, J.F. Silverman, Y. Liu, C.D. Sturgis, D.M. Grzybicki, and L.K. Mahood Cytohistologic discrepancies: a means to improve pathology practice and patient outcomes Am J Clin Pathol 117 2002 567 573
27. H.M. McBroom, and A.D. Ramsay The clinicopathological meeting. A means of auditing performance Am J Surg Pathol 17 1993 75 80
28. K. Aldape, M.L. Simmons, R.L. Davis, R. Miike, J. Wiencke, G. Barger, M. Lee, P. Chen, and M. Wrensch Discrepancies in diagnoses of neuroepithelial neoplasms Cancer 88 2000 2342 2349
29. Z.K. Arbiser, A.L. Folpe, and S.W. Weiss Consultative (expert) second opinions in soft tissue pathology. Analysis of problem-prone diagnostic situations Am J Clin Pathol 116 2001 473 476
30. D. Gupta, and L.J. Layfield Prevalence of inter-institutional anatomic pathology slide review: a survey of current practice Am J Surg Pathol 24 2000 280 284
31. K. Naik, and M.S. Zaleski Professional standards and human resources survey results: part II ASC Bull 38 2001 117 121
32. S.J. Adad, M.A. Souza, R.M. Etchebehere, J.C. Saldanha, V.A. Falco, and E.F. Murta Cyto-histological correlation of 219 patients submitted to surgical treatment due to diagnosis of cervical intraepithelial neoplasia São Paulo Med J 117 1999 81 84
33. R. Bakhos, S.M. Selvaggi, S. DeJong, D.L. Gordon, S.U. Pitale, and M. Herrmann Fine-needle aspiration of the thyroid: rate and causes of cytohistopathologic discordance Diagn Cytopathol 23 2000 233 237
34. J.M. Bruner, L. Inouye, G.N. Fuller, and L.A. Langford Diagnostic discrepancies and their clinical impact in a neuropathology referral practice Cancer 79 1997 796 803
35. P.N. Furness, and I. Lauder A questionnaire-based survey of errors in diagnostic histopathology throughout the United Kingdom J Clin Pathol 50 1997 457 460
36. M. Jorda, L. Rey, A. Hanly, and P. Ganjei-Azar Fine-needle aspiration cytology of bone: accuracy and pitfalls of cytodiagnosis Cancer 90 2000 47 54
37. S. Labbe, and A. Petitjean False negatives and quality assurance in cervico-uterine cytology Ann Pathol 19 1999 457 462
38. E. Lerma, V. Fumanal, A. Carreras, E. Esteva, and J. Prat Undetected invasive lobular carcinoma of the breast: review of false negative smears Diagn Cytopathol 23 2000 303 307
39. R. Logrono, D.F. Kurtycz, C.P. Molina, V.A. Trivedi, J.Y. Wong, and K.P. Block Analysis of false-negative diagnoses on endoscopic brush cytology of biliary and pancreatic duct strictures: the experience at 2 university hospitals Arch Pathol Lab Med 124 2000 387 392
40. L. MacDonald, and H.M. Yazdi Fine needle aspiration biopsy of Hashimoto's thyroiditis. Sources of diagnostic error Acta Cytol 43 1999 400 406
41. R.E. Nakhleh, and R.J. Zarbo Amended reports in surgical pathology and implications for diagnostic error detection and avoidance Arch Pathol Lab Med 122 1998 303 309
42. S. Naryshkin The false-negative fraction for Papanicolaou smears: how often are "abnormal" smears not detected by a "standard" screening cytologist? Arch Pathol Lab Med 121 1997 270 272
43. A.A. Renshaw Measuring and reporting errors in surgical pathology. Lessons from gynecologic cytology Am J Clin Pathol 115 2001 338 341
44. E. Ruijter, G. van Leenders, G. Miller, F. Debruyne, and C. van de Kaa Errors in histological grading by prostatic needle biopsy specimens: frequency and predisposing factors J Pathol 192 2000 229 233
45. C.J. Stewart, K. MacKenzie, G.W. McGarry, and A. Mowat Fine-needle aspiration cytology of salivary gland: a review of 341 cases Diagn Cytopathol 22 2000 139 146
46. D.B. Troxel, and J.D. Sabella Problem areas in pathology practice uncovered by a review of malpractice claims Am J Surg Pathol 18 1994 821 831
47. S.L. Wakely, J.A. Baxendine-Jones, P.J. Gallagher, M. Mullee, and R. Pickering Aberrant diagnoses by individual surgical pathologists Am J Surg Pathol 22 1998 77 82
48. I.M. Zardawi, G. Bennett, S. Jain, and M. Brown Internal quality assurance activities of a surgical pathology department in an Australian teaching hospital J Clin Pathol 51 1998 695 699
49. P. Bethwaite, N. Smith, B. Delahunt, and D. Kenwright Reproducibility of new classification schemes for the pathology of ductal carcinoma in situ of the breast J Clin Pathol 51 1998 450 454
50. D.K. Gupta, G. Komaromy-Hiller, S.S. Raab, and M.E. Nath Interobserver and intraobserver variability in the cytologic diagnosis of normal and abnormal metaplastic squamous cells in Pap smears Acta Cytol 45 2001 1 7
51. M. Plummer, E. Buiatti, G. Lopez, S. Peraza, J. Vivas, and W. Oliver Histological diagnosis of precancerous lesions of the stomach: a reliability study Int J Epidemiol 26 1997 716 720
52. S.S. Raab, K.R. Geisinger, J.F. Silverman, P.A. Thomas, and M.W. Stanley Interobserver variability of a Pap smear diagnosis of atypical glandular cells of undetermined significance (AGUS) Am J Clin Pathol 110 1998 653 659
53. S.S. Raab, R.A. Robinson, C.S. Jensen, D. Ozkutlu, P.O. O'Reilly, and V.H. Savell Mucinous tumors of the ovary: interobserver variability and utility of sectioning protocols Arch Pathol Lab Med 121 1997 1192 1198
54. S.S. Raab, R.A. Robinson, T.E. Snider, H.L. McDaniel, J.D. Sigman, and C.J. Leigh Telepathology on a difficult case consultation service: utility, diagnostic accuracy and interobserver variability Mod Pathol 10 1997 630 635
55. S.S. Raab, T.E. Snider, S.A. Potts, H.L. McDaniel, R.A. Robinson, and D.L. Nelson Atypical glandular cells of undetermined significance: diagnostic accuracy and interobserver variability using select cytologic criteria Am J Clin Pathol 107 1997 299 307
56. D.R. Salomão, A.C. Clayton, G.L. Keeney, K.R. Geisinger, J.F. Silverman, and S.S. Raab Reproducibility of proposed cytologic criteria to discriminate hepatocellular carcinoma (HCC) from metastatic adenocarcinoma (MA) in fine needle aspiration (FNA) Acta Cytol 45 2001 857
57. G.N. Gephardt, and R.J. Zarbo Interinstitutional comparison of frozen section consultations: a College of American Pathologists Q-PROBES study of 90,538 cases in 461 institutions Arch Pathol Lab Med 120 1996 804 809
58. B.A. Jones, and D.A. Novis Cervical biopsy-cytology correlation: a College of American Pathologists Q-PROBES study of 22,439 correlations in 348 laboratories Arch Pathol Lab Med 120 1996 523 531
59. B.A. Jones, and D. Davey Quality management in gynecologic cytology using interlaboratory comparison Arch Pathol Lab Med 124 2000 672 681
60. R. Zarbo, and C.M. Fenoglio-Preiser Interinstitutional database for comparison of performance in lung fine needle aspiration cytology: a College of American Pathologists Q-PROBES study of 5264 cases with histologic correlation Arch Pathol Lab Med 116 1992 463 470
61. R.J. Zarbo, G.G. Hoffman, and P.J. Howanitz Interinstitutional comparison of frozen section consultation: a College of American Pathologists Q-PROBES study of 79647 consultations in 297 North American institutions Arch Pathol Lab Med 115 1991 1187 1194
62. R.J. Zarbo, P.J. Howanitz, and P. Bachner Interinstitutional comparison of performance in breast fine needle aspiration cytology: a Q-PROBES quality indicator Arch Pathol Lab Med 115 1991 743 750
63. D.L. Nassar, L.K. Mahood, J.L. Condel, C.D. Sturgis, Y. Liu, and S.S. Raab Panel review of cytotechnologist-cytopathologist discrepancies: variance rather than error is a more appropriate means to measure performance Acta Cytol 44 2000 874
64. D.M. Grzybicki, C.M. Vrbin, K.M. Clary, M.S. Zaleski, M.B. Cohen, and J.F. Silverman Comparison of pathology errors across two institutions Mod Pathol 15 2002 332A
65. R.J. Zarbo Q-TRACKS intraoperative consultations: frozen section correlation. 2000 annual summary 2001 College of American Pathologists Northfield (IL)
66. R.J. Zarbo Q-TRACKS intraoperative consultations: frozen section correlation. 2001 annual summary 2002 College of American Pathologists Northfield (IL)
67. B.A. Jones, and S.S. Raab Q-TRACKS cytology-histology correlations. 2001 annual summary 2002 College of American Pathologists Northfield (IL)
68. J.F. Stastny, K.R. Geisinger, C.W. Michael, S.S. Raab, C.N. Powers, and R.M. Davila Another quality assurance issue. Amended reports: what do we really know about them? Diagn Cytopathol 18 1998 67 70
69. S.S. Raab, K.M. Clary, and D.M. Grzybicki Improving pathology practice by review of cases presented at Chest Conference Mod Pathol 67 2003 312A 313A
70. L.K. Mahood, C.D. Sturgis, and S.S. Raab Cytotechnologist report cards: creation of a standardized measure of quality and performance indicators Acta Cytol 44 2000 875
71. S.S. Raab, M.W. Stanley, P.R. Olson, N. Brewer, and J.F. Silverman The utility of pathologist and practice report cards Mod Pathol 13 2000 219A
72. J.B. Battles, H.S. Kaplan, T.W. Van der Schaaf, and C.E. Shea The attributes of medical event reporting systems: experience with a prototype medical event reporting system for transfusion medicine Arch Pathol Lab Med 122 1998 231 238
73. C.M.B. Fernandes, R. Walker, A. Price, J. Marsden, and L. Haley Root cause analysis of laboratory delays to an emergency department J Emerg Med 15 1997 735 739
74. G. Isouard Uncovering the causes of poor quality pathology laboratory services in acute myocardial infarction J Qual Clin Pract 18 1998 233 239
75. U. Baandrup, J.W. Bishop, T.A. Bonfiglio, M. Branca, M.L. Hutchinson, and C.R. Lavertty Sampling, sampling errors and specimen preparation Acta Cytol 44 2000 944 948
76. E. Foucar "Individuality" in the specialty of surgical pathology. Self-expression or just another source of diagnostic error? Am J Surg Pathol 24 2000 1573 1576
77. L.B. Rorke Pathologic diagnosis as the gold standard Cancer 79 1997 665 667
78. M.A. Thomson O'Brien, A.D. Oxman, D.A. Davis, R.B. Haynes, N. Freemantle, and E.L. Harvey Audit and feedback: effects on professional practice and health care outcomes Cochrane Database Syst Rev 2 2000 CD000259
79. C. Behr, C. Mercier, and J. Schriefer Strategies for involving physicians in continuous quality improvement J Healthc Qual 18 1996 21 23
80. N.S. Weinberg, and W.B. Stason Managing quality in hospital practice Int J Qual Health Care 10 1998 295 302
81. J.P. Bagian, C. Lee, J. Gosbee, J. DeRosier, E. Stalhandske, and N. Eldridge Developing and deploying a patient safety program in a large health care delivery system: you can't fix what you don't know about J Qual Improv 27 2001 522 532
82. D.W. Bates, M. Cohen, L.L. Leape, J.M. Overhage, M.M. Shabot, and T. Sheridan Reducing the frequency of errors in medicine using information technology J Am Med Inform Assoc 8 2001 299 308
83. A. Sheikh, and B. Hurwitz A national database of medical error J R Soc Med 92 1999 554 555
84. A. Sheikh, and B. Hurwitz Setting up a database of medical error in general practice: conceptual and methodological considerations Br J Gen Pract 51 2001 57 60
85. K.V. Arom, R.J. Petersen, T.A. Orszulak, R.M. Bolman, P.H. Wickstrom, and L.D. Joyce Establishing and using a local/regional cardiac surgery database Ann Thorac Surg 64 1997 1245 1249
86. F.L. Grover The Society of Thoracic Surgeons national database: current status and future directions Ann Thorac Surg 68 1999 367 373
87. J.C. Niland NCCN outcomes research database: data collection via the Internet Oncology 14 2000 100 103