—  SHORT COURSE #67  —

The Anatomic Pathologist's Role in Error Reduction and Patient Safety

References

Jan Silverman and William Frable


References


Quality Assurance
  1. Nakhleh, RE, Gephardt G, Zarbo RJ. Necessity of clinical information in surgical pathology. A College of American Pathologists Q-probes study of 771475 surgical pathology cases from 341 institutions. Arch Pathol Lab Med 123:615-619, 1999.

  2. Whitehead ME, Fitzwater JE, Lindley SK, Kern SB, Ulirsch RC, Winecoff WF. Quality assurance of histopathologic diagnoses: a prospective audit of three thousand cases. Am J Clin Pathol 81: 487-491, 1984.

  3. Zarbo RJ. Monitoring anatomic pathology practice through quality assurance measures. Outcomes in Pathology 19(4); 713-743, 1999.

  4. Nakhleh RE, Zarbo RJ. Surgical pathology specimen identification and accessioning. A College of American Pathologists Q-probes study of 1004115 cases from 417 institutions. Arch Pathol Lab Med 120: 227-233, 1996.

  5. Nakhleh RE, Zarbo RJ. Amended reports in surgical pathology and implications for diagnostic error detection and avoidance. A College of American Pathologists Q-probes study of 1667547 accessioned cases in 359 laboratories. Arch Pathol Lab Med 122: 303-309, 1998.

  6. Travers H. Quality assurance indicators in anatomic pathology. Arch Pathol Lab Med 114: 1149-1156, 1990.

  7. Rickert RR. Quality assurance goals in surgical pathology. Arch Pathol Lab Med 114: 1157-1162, 1990.

  8. Zardawi IM, Bennett G, Jain S, Brown M. Internal quality assurance activities of a surgical pathology department in an Australian teaching hospital. Am J Clin Pathol 51: 695-699, 1998.

  9. Jukic DM. Pathologist as the final quality assurance officer, or "The buck stops here". Pathology Case Reviews 10(2): 88-94, 2005.

  10. Bonfiglio TA, Corson JM, Fechner RE, Harris NL, Livolsi VA, Rosai J, Silverberg SG. Association of Directors of Anatomic and Surgical Pathology. Recommendations on quality assurance in anatomic pathology. Am J Surg Pathol 15(10): 1007-1009, 1991.

  11. Stastny JF, Geisinger KR, Michael CW, Raab SS, Powers CN, Davila RM. Another quality assurance issue - amended reports: What do we really know about them? Diagn Cytopathol 18: 67-70, 1998.

  12. Emancipator K. Critical values. ASCP practice parameter. Am J Clin Pathol 108: 247-253, 1997.

  13. Pereira TC, Liu Y, Silverman JF. Critical values in surgical pathology. Am J Clin Pathol 122: 201-205, 2004.

  14. LiVolsi VA. Critical values in anatomic pathology. How do we communicate? Am J Clin Pathol 122: 171-172, 2004.

  15. Silverman JF, Pereira TC. Critical values in Anatomic Pathology. Arch Pathol Lab Med 130: 638-640, 2006.

  16. Howanitz PJ, Steindel SJ, Heard NV. Laboratory critical values policies and procedures. A College of American Pathologists Q-probes study in 623 institutions. Arch Pathol Lab Med 126: 663-669, 2002.

  17. Zarbo RJ. Quality assessment in anatomic pathology in the cost-conscious era. Am J Clin Pathol 106(Suppl 1):S3-S10, 1996.

  18. Methods in pathology. Recommendations on quality control and quality assurance in surgical pathology and autopsy pathology. QA/QC Committee: Rosai J, Chairperson, Bonfiglio TA, Corson MJ, Fechner RE, Harris NL, Livolsi VA, Silverberg SG. Mod Pathol 5(5):567-568, 1992.

  19. LiVolsi VA, Leung S. Communicating critical values in anatomic pathology. Arch Pathol Lab Med 130: 641-644, 2006.

  20. Zarbo RJ. Determining customer satisfaction in anatomic pathology. Arch Pathol Lab Med 130: 645-649, 2006.

  21. Pereira TC, Clayton AC, Tazelaar HD, Liu Y, Leon M, Silverman JF. Critical values in cytology. Diagn Cytopathol 34: 447-451, 2006.

  22. Marchevsky AM. Evidence-based medicine in pathology: an introduction. Semin Diagn Pathol 22: 105-115, 2005.

  23. Wick MR, Bourne T, Patterson JW, Mills SE. Evidence-based principles and practices in pathology: selected problem areas. Semin Diagn Pathol 22: 116-125, 2005.

  24. Foucar E, Wick MR. An observational examination of the literature in diagnostic anatomic pathology. Semin Diagn Pathol 22: 126-138, 2005.

  25. Marchevsky AM. The application of special technologies in diagnostic anatomic pathology: is it consistent with the principles of evidence-based medicine? Semin Diagn Pathol 22: 156-166, 2005.

  26. Fletcher DCM. Symposium on errors, error reduction, and critical values in anatomic pathology. Arch Pathol Lab Med 130: 602-606, 2006.

  27. Silverman JF, LiVolsi V, Fletcher CDM, Frable WJ, Goldblum JR, Pereira TC, Swanson PE. (Association of Directors of Anatomic and Surgical Pathology). Critical Diagnoses (Critical Values) in Anatomic Pathology. Am J Clin Pathol 125: 815-817, 2006; Am J Surg Pathol 30: 897-899, 2006.

  28. Nakhleh RE, Souers R, Brown RW. Critical results (diagnoses) in anatomic pathology: A College of American Pathologists Survey of 1130 Laboratories. Arch Pathol Lab Med 2008;132:1523.

  29. Huang EC, Nose V. Critical values in surgical pathology: continuous monitoring to improve patient safety. Laboratory Investigation 2008;88(1):355A.

  30. Kalra A, Nunes EC, Huang EC, et al. Monitoring critical values in medical kidney diseases: a step towards quality of care. Laboratory Investigation 2008;88(1):356A.

  31. Coffin CM, Spilker K, Lowichik A, et al. Critical values in pediatric surgical pathology: policy development, process implementation, and reporting in a Children's Hospital. Mod Pathol 2007;20(2);336A.

  32. Huang EC, Kuo FC, Fletcher CDM, Nose V. Critical values in surgical pathology: a retrospective study to establish guidelines for communication of urgent results. Mod Pathol 2007;20(2);338A.

  33. Myers J. How safe is safe enough? Ask a patient. Arch Pathol Lab Med 2006;130:1103-1104.

  34. Silverman JF, Pereira TC. The concept and application of critical diagnoses (critical values) in anatomic pathology. Pathology Case Reviews 14(2), 66-68, 2009.

  35. Pereira TC, Silverman JF. Anatomic pathology quality and safety monthly conference: The pathology version of morbidity and mortality conference. Pathology Case Reviews 14(2), 69-72, 2009.

  36. Frable WJ. Risk management in gynecologic and nongynecologic cytology. Pathology Case Reviews 14(2), 73-82, 2009.

Second Opinion
  1. Azam M, Nakhleh RE. Surgical pathology extradepartmental consultation practices. A College of American Pathologists Q-probes study of 2746 consultations from 180 laboratories. Arch Pathol Lab Med 126:405-412, 2002.

  2. Kronz JD, Westra WH, Epstein JI. Mandatory second opinion surgical pathology at a large referral hospital. Cancer 86(11): 2426-2435, 1999.

  3. Rosai J. Borderline epithelial lesions of the breast. Am J Surg Pathol 15(3): 209-221, 1991.

  4. Safrin RE, Bark CJ. Surgical pathology signout. Routine review of every case by a second pathologist. Am J Surg Pathol 17(11): 1190-1192. 1993.

  5. Lind AC, Bewtra C, Healy JC, Sims KL. Prospective peer review in surgical pathology. Am J Clin Pathol 104: 560-566, 1995.

  6. Tsung JSH. Institutional pathology consultation. Am J Surg Pathol 28(3): 399-402, 2004.

  7. Renshaw AA, Pinnar NE, Jiroutek MR, Young ML. Quantifying the value of in-house consultation in surgical pathology. Am J Clin Pathol 117: 751-754, 2002.

  8. Ramsay AD, Gallagher PJ. Local audit of surgical pathology. 18 month's experience of peer review-based quality assessment in English teaching hospital. Am J Surg Pathol 16(5): 476-482, 1992.

  9. Renshaw AA, Young ML, Jiroutek MR. Many cases need to be reviewed to compare performance in surgical pathology? Am J. Clin Pathol 119: 1-4, 2003.

  10. Gupta D, Layfield LJ. Prevalence of inter-institutional anatomic pathology slide review. A survey of current practice. Am J Surg Pathol 24(2): 280-284, 2000.

  11. Renshaw AA, Pinnar NE, Jiroutek MR, Young ML. Blinded review as a method for quality improvement in surgical pathology. Arch Pathol Lab Med 126: 961-963, 2002.

  12. Westra WH, Kronz JD, Eisele DW. The impact of second opinion surgical pathology on the practice of head and neck surgery: a decade experience at a large referral hospital. Head Neck 24: 684-693, 2002.

  13. Abt AB, Abt LG, Olt GJ. The effect of interinstitution anatomic pathology consultation on patient care. Arch Pathol Lab Med 119: 514-517, 1995.

  14. Novis D. Routine review of surgical pathology cases as a method by which to reduct diagnostic errors in a community hospital. Pathology Case Reviews 10(2): 63-67, 2005.

  15. Leslie KO, Fechner RE, Kempson RL. Second opinions in surgical pathology. Am J Clin Pathol 106(Supp 1): S58-S64, 1996.

  16. Nordrum I, Johansen M, Amin A, Isaksen V, Ludvigsen JA. Diagnostic accuracy of second-opinion diagnoses based on still images. Hum Pathol 35: 129-135, 2004.

  17. Tomaszewski JE, Bear HD, Connally JA, Epstein JI, Feldman M, Foucar K, Layfield L, LiVolsi V, Sirota RL, Stoler MH, Stombler RE. Consensus conference on second opinions in diagnostic anatomic pathology. Who, what, and when. Am J Clin Pathol 114: 329-335, 2000.

  18. Silverberg SG, Corson JM, Dehner LP, Fechner RE, Frable WJ, Kempson RL, LiVolsi VA, Weiss SW, Norris HJ. Association of Directors of Anatomic and Surgical Pathology. Consultations in surgical pathology. Am J Surg Pathol 17(7): 743-745, 1993.

  19. Weydert JA, DeYoung BR, Cohen MB. A preliminary diagnosis service provides prospective blinded dual-review of all general surgical pathology cases in an academic practice. Am J Surg Pathol 29: 801-805, 2005.

  20. Weir MM, Jan E, Colgan TJ. Interinstitutional pathology consultations. A reassessment. Am J Clin Pathol 120:405-412, 2003.

  21. Layfield LJ, Jones C, Rowe L, Gopez EV. Institutional review of outside cytology materials: A retrospective analysis of two institutions' experiences. Diagn Cytopathol 26(1):45-48, 2002.

  22. Silverberg SG. The institutional pathology consultation. Documentation of its importance in patient management. Arch Pathol Lab Med 119:514-517, 1995.

  23. Selman AE, Ninemann TH, Fowler JM, Copeland LJ. Quality assurance of second opinion pathology in gynecologic oncology. Obstet Gynecol 94:302-306, 1999.

  24. Bruner JM, Inouye L, Fuller GN, Langford LA. Diagnostic discrepancies and their clinical impact in a neuropathology referral practice. Cancer 79(4):796-803, 1997.

  25. Wurzer JC, Al-Saleem TI, Hanlon AL, Freedman GM, Patchefsky A, Hanks GE. Histopathologic review of prostate biopsies from patients referred to a comprehensive cancer center. Correlation of pathologic findings, analysis of cost, and impact on treatment. Cancer 83(4):753-759, 1998.

  26. Wetherington RW, Cooper HS, Al-Saleem T, Ackerman DS, Adams-McDonnell R, et al. Clinical significance of performing immunohistochemistry on cases with a previous diagnosis of cancer coming to a national comprehensive cancer center for treatment or second opinion. Am J Surg Pathol 26(9): 1222-1230, 2002.

  27. Fitzgibbons RL, Compton CC. Be careful what you wish for. On calls for mandatory second opinion. Arch Pathol Lab Med 125:602-603, 2001.

  28. Arbiser ZK, Folpe AL, Weiss SW. Consultative (expert) second opinions in soft tissue pathology. Analysis of problem-prone diagnostic situations. Am J Clin Pathol 116:473-476, 2001.

  29. Leslie KO, Fechner RE, Kempson RL. Second opinions in surgical pathology. Am J Clin Pathol 106(Suppl 1):S58-S64, 1996.

  30. Frable WJ. Surgical pathology-second reviews, institutional reviews, audits, and correlations. What's out there? Error or diagnostic variation? Arch Pathol Lab Med 130: 620-625, 2006.

  31. Renshaw AA. Prospective and retrospective second reviews and audits in anatomic pathology: Issues in implementation and interpretation. Pathology Case Reviews 14(2), 57-61, 2009.

  32. Lueck N, Manion EM, Cohen MB, Weydert JA. Institutional second opinion. Pathology Case Reviews 14(2), 62-65, 2009.

Errors
  1. Renshaw AA. Measuring and reporting errors in surgical pathology. Lessons from gynecologic cytology. Am J Clin Pathol 115: 338-341, 2001.

  2. Nakhleh RE, Zarbo RJ. Amended reports in surgical pathology and implications for diagnostic error detection and avoidance. A College of American Pathologists Q-probes study of 1667547 accessioned cases in 359 laboratories. Arch Pathol Lab Med 122: 303-309, 1998.

  3. James BC, Hammond EH. The challenge of variation in medical practice. Arch Pathol Lab Med 124: 1001-1003, 2000.

  4. Renshaw AA, Cartagena N, Granter SR, Gould EW. Agreement and error rates using blinded review to evaluate surgical pathology of biopsy material. Am J Clin Pathol 119: 797-800, 2003.

  5. Barenfanger J, Sautter RL, Lang DL, Collins SM, Hacek DM, Peterson LR. Improving patient safety by repeating (read-back) telephone reports of critical information. Am J Clin Pathol 121: 801-803, 2004.

  6. Wieman TJ, Wieman EA. A systems approach to error prevention in medicine. J Surg Oncol 88: 115-121, 2004.

  7. Foucar E. "Individuality" in the specialty of surgical pathology. Self-expression or just another source of diagnostic error. Am J Surg Pathol 12(11): 1573-1576, 2000.

  8. Foucar E. Error identification. A surgical pathology dilemma. Am J Surg Pathol 22(1): 1-5, 1998.

  9. Goldstein NS. Diagnostic errors in surgical pathology. Outcomes in Pathol 19(4), 743-757, 1999.

  10. Schnitt SJ, Connolly JL, Tavassoli FA, Fechner RE, Kempson RL, Gelman R, Page DL. Interobserver reproducibility in the diagnosis of ductal proliferative breast lesions using standardized criteria. Am J Surg Pathol 16(12): 1133-1143, 1992.

  11. Foucar E. Error in anatomic pathology. Am J Clin Pathol 116(Suppl 1): S34-S46, 2001.

  12. Bruner JM, Inouye L, Fuller GN, Langford LA. Diagnostic discrepancies and their clinical impact in neuropathology referral practice. Cancer 79: 796-803, 1997.

  13. Cramer SF. Interobserver variability in surgical pathology. Adv in Pathol 9: 3-82, 1996.

  14. Wakely, SL, Baxendine-Jones JA, Gallagher PJ, Mullee M, Pickering R. Aberrant diagnoses by individual surgical pathologists. Am J Surg Pathol 22(1): 77-82, 1998.

  15. Powsner SM, Costa J, Homer RJ. Clinicians are from Mars and pathologists are from Venus. Arch Pathol Lab Med 124: 1040-1046, 2000.

  16. Ruby SG. Clinician interpretation of pathology reports. Confusion or comprehension? Arch Pathol Lab Med 124: 143-144, 2000.

  17. Leape LL. Error in medicine. JAMA 272(23): 1851-1857, 1994.

  18. Leape LL. Institute of medicine medical error figures are not exaggerated. JAMA 284(1): 95-97, 2000.

  19. Hollensead SC, Lockwood WB, Elin RJ. Errors in pathology and laboratory medicine: consequences and prevention. J Surg Oncol 88: 161-181, 2004.

  20. Bates DW, Cohen M, Leape LL, Overhage M, Shabot M, Sheridan T. Reducing the frequency of errors in medicine using information technology. J Am Med Inform Assoc 8: 299-308, 2001.

  21. Sirota RL. The Institute of Medicine's report on medical error. Implications for pathology. Arch Pathol Lab Med 124:1674-1678, 2000.

  22. Cooper K. Errors and error rates in surgical pathology. An Association of Directors of Anatomic and Surgical Pathology. Arch Pathol Lab Med 130: 607-609, 2006.

  23. Coffin CM. Pediatric surgical pathology. Pitfalls and strategies for error prevention. Arch Pathol Lab Med 130: 610-612, 2006.

  24. Renshaw AA, Gould EW. Correlation of workload with disagreement and amendment rates in surgical pathology and nongynecologic cytology. Am J Clin Pathol 125: 820-822, 2006.

  25. Foucar E. Diagnostic precision and accuracy in interpretation of specimens from cancer screening programs. Semin Diagn Pathol 22: 147-155, 2005.

  26. Foucar E. Classification of error in anatomic pathology: a proposal for an evidence-based standard. Semin Diagn Pathol 22: 139-146, 2005.

  27. Nakhleh RE. Error reduction in surgical pathology. Arch Pathol Lab Med 130: 630-632, 2006.

  28. Renshaw AA. Comparing methods to measure error in gynecologic cytology and surgical pathology. Arch Pathol Lab Med 130: 626-629, 2006.

  29. McLendon RE. Errors in surgical neuropathology and the influence of cognitive biases. The psychology of intelligence analysis. Arch Pathol Lab Med 130: 613-616, 2006.

  30. Renshaw AA, Gould EW. Comparison of disagreement and error rates for three types of interdepartmental consultations. Am J Clin Pathol 124: 878-882, 2005.

  31. Renshaw AA, Gould EW. Measuring errors in surgical pathology in real-life practice. Defining what does and does not matter. Am J Clin Pathol 127:144-152, 2007.

  32. Weydert JA, DeYoung BR, Cohen MB. A preliminary diagnosis service provides prospective blinded dual-review of all general surgical pathology cases in an academic institution. Am J Surg Pathol 29:801-805, 2003.

  33. Renshaw AA, Gould EW. Correlation of workload with disagreement and amendment rates in surgical pathology and nongynecologic cytology. Am J. Clin Pathol 125:820-822, 2006.

  34. Renshaw AA, Gould EW. Comparison of disagreement and amendment rates by tissue type and diagnosis: identifying cases for directed blinded review. Am J. Clin Pathol 126:736-739, 2006.

  35. Renshaw AA, Gould EW. Measuring the value of review of pathology material by a second pathologist. Am J Clin Pathol 125:737-739, 2006.

  36. Renshaw AA, Gould EW. Comparison of disagreement and error rates for three types of interdepartmental consultations. Am J Clin Pathol 124:878-882, 2005.

  37. Sirota RL. A framework for error in anatomic pathology. Pathology Case Reviews 14(2), 53-56, 2009.

Medical Legal
  1. Troxel DB. Pitfalls in the diagnosis of malignant melanoma. Findings of a risk management panel study. Am J Surg Pathol 27(9): 1278-1283, 2003.

  2. Farmer ER, Gonin R, Hanna MP. Discordance in the histopathologic diagnosis of melanoma and melanocytic nevi between expert pathologists. Human Pathol 27(6): 528-531, 1996.

  3. Troxel DB, Sabella JD. Problem areas in pathology practice: uncovered by a review o malpractice claims. Am J Surg Pathol 18:821-831, 1994.

  4. Troxel DB. Diagnostic pitfalls in surgical pathology: uncovered by a review of malpractice claims, part II: breast fine needle aspirations. Int J Surg Pathol 8:229-231, 2000.

  5. Troxel DB. Diagnostic pitfalls in surgical pathology: discovered by a review of malpractice claims, part III: breast biopsies. Int J Surg Pathol 8:335-337, 2000.

  6. Troxel DB. Diagnostic pitfalls in surgical pathology: discovered by a review of malpractice claims, part VII: random errors. Int J Surg Pathol 9:305-308, 2001.

  7. Troxel DB. Pitfalls in the diagnosis of malignant melanoma: findings of a risk management panel study. Am J Surg Pathol 27:1278-1283, 2003.

  8. Troxel DB. Error in surgical pathology. Am J Surg Pathol 28:1092-1095, 2004.

  9. Epstein JI. Pathologists and the judicial process: how to avoid it. Am J Surg Pathol 25:527-537, 2001.

  10. Troxel DB. Medicolegal aspects of error in pathology. Arch Pathol Lab Med 130: 617-619, 2006.

  11. Wick MR, Foucar E. Evidence-based medicine and tort law. Semin Diagn Pathol 22: 167-176, 2005.