Symposium on Errors, Error Reduction, and Critical Values in Anatomic Pathology Open Access

There is no question that anatomic pathologists (and pathology laboratories), like all other medical practitioners, sometimes make mistakes. Happily, these appear to be few in number, and most mistakes have minimal clinical impact or are easily corrected after the fact. A small number of such errors, however, have major clinical implications for the patient's care and clinical outcome. All errors are regrettable, and we have a duty to minimize errors of all types to avoid errors that have major clinical consequences. The Institute of Medicine report,1 published in 1999, focused particular attention on medical error. In identifying what was believed to be the substantial scale of the problem, the report garnered considerable public attention, thereby raising levels of patient expectation and doubt, while further eroding the traditional paternalistic “we know best” attitude that has often prevailed in the medical profession.

Quality control, performance evaluation, and test reproducibility have always been more easily defined and applied in clinical laboratory medicine than in anatomic pathology. Despite the fact that our specialty is by definition, at least for now, largely an interpretive and subjective skill, we are increasingly held to standards usually applied to machines. There are many who seem to regard any difference in opinion or any perceived error of interpretation as a form of negligence, a position that is often unjustified. Many of the most significant errors result from mistakes or carelessness in the preanalytic phase (eg, specimen, block, or slide labeling), and it is reasonable for patients and their clinicians to expect that we reduce this type of error to an absolute minimum. At all stages of the analytic process, it seems evident that automation (eg, bar coding) and standardization (eg, synoptic reporting formats), where applicable, lead to error reduction.

As errors and error reduction are increasingly the focus of attention in anatomic pathology and because there are few data and little consensus as to the best means of addressing these issues, the Association of Directors of Anatomic and Surgical Pathology (ADASP) devoted its February 26, 2005, 15th Annual Meeting to this topic. In doing so, we attempted to gather speakers who are national leaders in this field, and we initiated small surveys to raise awareness, generate more unified approaches to the problems, and obtain a limited and informal impression of how errors are defined and addressed in larger academic pathology practices across the country. The results in this regard are troubling, as you will see from the article by Cooper in this issue of the Archives. Defining errors in various areas of anatomic pathology, a series of outstanding presentations reviewed the potential consequences of error and the methods for measuring and reducing error in our field. There is some partial overlap with the presentations that emanated from the College of American Pathologists Special Topic Symposium on Error in Pathology and Laboratory Medicine—Practical Lessons for the Pathologist, which (with neither group being aware of the other's plans) took place just 5 months earlier and elements of which were published in this journal in October 2005. Given the importance of this topic, reinforcement is worthwhile.

We also took this opportunity to initiate broader discussion regarding critical values in anatomic pathology, which, again, have been better and more easily defined in clinical laboratory medicine. As patient safety becomes a clear focus for performance improvement at institutional and federal (Joint Commission on Accreditation of Healthcare Organization) levels, guidelines for the communication of urgent and important test results are increasingly deemed to be necessary. There seems to be limited agreement and considerable interinstitutional variation as to what types of results need to be transmitted urgently. In these times in which all physicians seem busier and more stressed, in an environment of multiple forms of communication (telephone, cell phone, fax, text messaging, e-mail, and regular mail), how such prioritized communication takes place becomes an issue. We all remember occasions when we have tried for hours to relay an urgent result to a colleague and the inaccessibility of the clinician was entirely justified (eg, left for vacation), but lines of communication in our hospitals and other practices are often loosely defined at best.

The articles in this special section of the Archives represent the written summaries of the impressive series of lectures that were given at the February 2005 ADASP annual meeting in San Antonio, Tex. I believe that this important body of work provides clear evidence that there is a need for substantial improvement and development of more uniform approaches in the identification, definition, and reduction of errors in anatomic pathology at all stages of the analytic process. Now is also the time to follow the lead of Silverman and Pereira (see their article “Critical Values in Anatomic Pathology” in this section) in establishing and efficiently communicating critical values in a consistent manner, recognizing the need for minor degrees of institutional variation. We owe our patients, our clinical colleagues, our trainees, and ourselves nothing less.