Interpretive Diagnostic Error Reduction in Surgical Pathology and Cytology: Guideline From the College of American Pathologists Pathology and Laboratory Quality Center and the Association of Directors of Anatomic and Surgical Pathology.

Nakhleh RE1, Nosé V, Colasacco C, Fatheree LA, Lillemoe TJ, McCrory DC, Meier FA, Otis CN, Owens SR, Raab SS, Turner RR, Ventura CB, Renshaw AA.

Author information

Abstract

CONTEXT:

Additional reviews of diagnostic surgical and cytology cases have been shown to detect diagnostic discrepancies.

OBJECTIVE:

To develop, through a systematic review of the literature, recommendations for the review of pathology cases to detect or prevent interpretive diagnostic errors.

DESIGN:

The College of American Pathologists Pathology and Laboratory Quality Center in association with the Association of Directors of Anatomic and Surgical Pathology convened an expert panel to develop an evidence-based guideline to help define the role of case reviews in surgical pathology and cytology. A literature search was conducted to gather data on the review of cases in surgical pathology and cytology.

RESULTS:

The panel drafted 5 recommendations, with strong agreement from open comment period participants ranging from 87% to 93%. The recommendations are: (1) anatomic pathologists should develop procedures for the review of selected pathology cases to detect disagreements and potential interpretive errors; (2) anatomic pathologists should perform case reviews in a timely manner to avoid having a negative impact on patient care; (3) anatomic pathologists should have documented case review procedures that are relevant to their practice setting; (4) anatomic pathologists should continuously monitor and document the results of case reviews; and (5) if pathology case reviews show poor agreement within a defined case type, anatomic pathologists should take steps to improve agreement.

CONCLUSIONS:

Evidence exists that case reviews detect errors; therefore, the expert panel recommends that anatomic pathologists develop procedures for the review of pathology cases to detect disagreements and potential interpretive errors, in order to improve the quality of patient care.

Comment in

Diagnostic Error in Anatomic Pathology. [Arch Pathol Lab Med. 2016]
In Reply. [Arch Pathol Lab Med. 2016]

PMID:: 25965939; [PubMed - indexed for MEDLINE]

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National Guideline Clearinghouse | Interpretive diagnostic error reduction in surgical pathology and cytology: guideline from the College of American Pathologists Pathology and Laboratory Quality Center and the Association of Directors of Anatomic and Surgical Pathology.

College of American Pathologists

Interpretive diagnostic error reduction in surgical pathology and cytology: guideline from the College of American Pathologists Pathology and Laboratory Quality Center and the Association of Directors of Anatomic and Surgical Pathology.

Guideline Title

Interpretive diagnostic error reduction in surgical pathology and cytology: guideline from the College of American Pathologists Pathology and Laboratory Quality Center and the Association of Directors of Anatomic and Surgical Pathology.

Bibliographic Source(s)

Nakhleh RE, Nosé V, Colasacco C, Fatheree LA, Lillemoe TJ, McCrory DC, Meier FA, Otis CN, Owens SR, Raab SS, Turner RR, Ventura CB, Renshaw AA. Interpretive diagnostic error reduction in surgical pathology and cytology: guideline from the College of American Pathologists Pathology and Laboratory Quality Center and the Association of Directors of Anatomic and Surgical Pathology. Arch Pathol Lab Med. 2016 Jan;140(1):29-40. [148 references] PubMed External Web Site Policy