Errors in Surgical Pathology

Errors in Anatomic Pathology
Extracts of the interview with Dr. Stephen Raab, Professor of Pathology, Vice-Chair for Quality and Director of Anatomic Pathology at the University of Colorado, Denver.
Q: How many errors have been reported to date ?

Dr. Raab: There are now more than 25,000 errors in the database.

Q: What are some area for quality improvement in anatomic pathology?
Dr. Raab: Quality improvement is more effective if there are simultaneous efforts to improve quality in specimen collection, laboratory processing, and pathologist interpretation, rather than just focusing on error in pathology interpretation.

Q: Error detection is critical to quality improvement. How are errors usually detected in anatomic pathology?
Dr. Raab: The two most common methods of error detection are cytologic-histologic correlation and secondary review of previously reported cases.

Q: What kind of errors do these methods detect?
Dr. Raab: They detect many different errors including mislabeled specimens, suboptimal specimens -for example a cytology or histology specimen that fails to sample the cancerous area of a mass-, and errors in interpretation by a pathologist.

Q: What is your general approach to interventions to decrease errors in anatomic pathology?
Dr. Raab: Enhanced communication. Disconnection between pathologists and direct care providers is a significant latent source of errors in pathology. When pathologists communicate more frequently with care providers, the quality of the pathologist's work improves because both the clinician and pathologist are better informed about the patients.
some examples of enhanced communication between pathologists and care providers are as follows:
1) Pathologists calling their diagnosis directly to the physician caring for the patient,
2) Increasing the number of conferences at the multiple-headed scope with both pathologists and care providers present,
3) Having the pathologist physically present when a different physician collects a fine needle aspirate.
4) The specimen collector, who is often a direct care provider or radiologist, receives immediate feedback from the pathologist regarding the adequacy of the specimen.
Using a checklist in the gynecologist office to maximize the likelihood of an adequate specimen.

Q: Besides increased communication, what other interventions do you favor regarding decreasing errors in pathologist interpretation?
Dr Raab: The key to decreasing errors in pathologist interpretation of an adequate specimen is standardization. Standardization is basically an agreement that work is going to be done a certain way. It requires that standards be developed at a national or international level, than adhered to by each pathology practice. To achieve standardization, the pathologists in the practice must work together as a group and apply methods such as:
1) Reviewing a sampling of each other's cases
2) Meeting frequently around the multiple-headed scope to decide cases by a consensus-building process.
Practices dominated by individualists or egotists tend to resist change and have trouble standardizing. Unfortunately, many practicing pathologists strongly resist standardization.

Q: What is the "Big Dog" effect ?
Dr. Raab: At many institutions, there is a dominant senior pathologist, the Big Dog, who becomes the gold standard of anatomic pathology. The other pathologists follow the diagnostic beliefs of the Big Dog, and defer to the Big Dog on difficult cases and in the analysis of the cause of an error.

Q: What are the problems caused by Big Dogs?
Dr. Raab: There is a poor agreement between Big Dogs from different institutions in their interpretation of a particular case. This makes it hard to achieve standardization regarding a diagnosis. In addition, Big Dogs agree poorly regarding their assessment of the causes of an error. This hinders quality improvement, since judgments regarding root causes of an error provide a guide for the choice of interventions.

References:
1. Raab SS et al. Patient safety in anatomic pathology: measuring discrepancy frequencies and causes. Arch Pathol Lab Med. 2005;129:459-466.
2. Raab SS et al. Errors in thyroid gland fine-needle aspiration. Am J Clin Pathol. 2006;125:873-882.