A critical component of improving patient safety is reducing medical errors. A paucity of information exists on anatomic pathology diagnostic errors and their effect on patient outcomes. Many previously published studies are limited to single institutions and report variable diagnostic error percentages from less than 1 percent to 43 percent of all patients who undergo a biopsy or excisional procedure, with no correlation between error and outcome. A major goal of this project is to establish a Web-based, pathologist-driven, national, voluntary anatomic pathology error database. These data will be used for continuous quality improvement targeted at error reduction and clinical outcomes improvement.
Four specific aims will be addressed. First, archival and on-going errors and their associated outcomes, detected by cytologic-histologic correlation and by secondary review of cases at interdepartmental conferences, will be identified retrospectively at four institutions and entered into the database. Each institution will enter their error data into the Web-based database on site, and the date will be sent electronically to the applicant institution for centralized analysis. Second, quarterly and annual quality performance reports, relating to these errors and outcomes, will be generated by the applicant institution research team and disseminated to each institution. These reports will include aggregate diagnostic error and outcome percentages, institution-specific error and outcome percentages, and aggregate and institution-specific error and outcome percentages stratified by multiple potential risk factors for error, such as specimen type. Quantitative analysis of these data will result in objective multi-institutional performance measures. Specific factors (e.g., specimen type, organ, clinical factors, pathologist and practice characteristics) associated with increased risk for diagnostic error will be identified. Third, root cause analysis will be performed to determine the potential sources of errors, and error reduction programs will be implemented at each institution, based on the results of the root cause analysis. Fourth, the success of these interventions will be determined by monitoring post-interventional error and the effects of error on patient outcomes. This project will provide valuable information regarding diagnostic pathology errors; it will set the groundwork for future studies focused on the examination of other types of diagnostic pathology error and the effect of error reduction programs in pathology practice.

Agency
National Institute of Health (NIH)
Institute
Agency for Healthcare Research and Quality (AHRQ)
Type
Research Project (R01)
Project #
5R01HS013321-05
Application #
7091402
Study Section
Health Care Technology and Decision Science (HTDS)
Program Officer
Henriksen, Kerm
Project Start
2002-09-16
Project End
2007-11-30
Budget Start
2006-09-01
Budget End
2007-11-30
Support Year
5
Fiscal Year
2006
Total Cost
Indirect Cost
Name
University of Pittsburgh
Department
Pathology
Type
Schools of Medicine
DUNS #
004514360
City
Pittsburgh
State
PA
Country
United States
Zip Code
15213
Raab, Stephen S; Grzybicki, Dana M (2011) Cytologic-histologic correlation. Cancer Cytopathol 119:293-309
Raab, Stephen S; Grzybicki, Dana M; Mahood, Laura K et al. (2008) Effectiveness of random and focused review in detecting surgical pathology error. Am J Clin Pathol 130:905-12
Meier, Frederick A; Zarbo, Richard J; Varney, Ruan C et al. (2008) Amended reports: development and validation of a taxonomy of defects. Am J Clin Pathol 130:238-46
Raab, Stephen S; Andrew-Jaja, Carey; Grzybicki, Dana M et al. (2008) Dissemination of Lean methods to improve Pap testing quality and patient safety. J Low Genit Tract Dis 12:103-10