title: Learning to improve safety: false-positive pathology report results in wrongful surgery.
abstract: BACKGROUND
  A patient experienced a wrongful surgical resection, specifically, a radical retropubic prostatectomy because of a false-positive pathology report.
  The RCA team identified three antecedent events that contributed to this medical error: (1) a second (concurring) pathologist did not provide a written opinion, (2) a single pathologist who reviewed and signed the final report, and (3) a pathologist who did not review the case and reconfirm the diagnosis immediately prior to the surgical resection.
  
  
  CONCLUSIONS
  The RCA team recommended that the concurring pathologist write his or her diagnostic findings on the referral form, two pathologists review and sign the final typed report, and a pathologist rereview the slides on the business day prior to a surgical resection. Because the prostate specific antigen (PSA) value can be helpful in select cases of prostate cancer, the team recommended the PSA value be referenced when reviewing prostate specimens obtained through fine-needle biopsy.
  Because a wrongful surgical resection is a rare event, emphasis was placed on measuring compliance with distinct elements that were part of the revised procedure. During a 12-month span, practitioners demonstrated sustained compliance to the enhanced process for analyzing and reporting results.
authors.affiliation: VA Ann Arbor Healthcare System, Michigan, USA. Marcia.Piotrowski@med.va.gov
authors.forename: Marcia M
authors.initials: MM
authors.lastname: Piotrowski
authors.forename: Roland L
authors.initials: RL
authors.lastname: Bessette
authors.forename: Stephen
authors.initials: S
authors.lastname: Chensue
authors.forename: Daniel
authors.initials: D
authors.lastname: Cutler
authors.forename: Allen
authors.initials: A
authors.lastname: Kachalia
authors.forename: James W
authors.initials: JW
authors.lastname: Roseborough
authors.forename: Sanjay
authors.initials: S
authors.lastname: Saint
authors.forename: Willie
authors.initials: W
authors.lastname: Underwood
authors.forename: Hedwig S
authors.initials: HS
authors.lastname: Murphy
mesh_terms: D000368:Aged; D003951:Diagnostic Errors; D005189:False Positive Reactions; D006801:Humans; D008297:Male; D019300:Medical Errors / Q000517:prevention & control*; D011471:Prostatic Neoplasms / Q000175:diagnosis* / Q000473:pathology*; D014481:United States