Learning to improve safety: false-positive pathology report results in wrongful surgery.
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.
Piotrowski
Marcia M
MM
VA Ann Arbor Healthcare System, Michigan, USA. Marcia.Piotrowski@med.va.gov
Bessette
Roland L
RL
Chensue
Stephen
S
Cutler
Daniel
D
Kachalia
Allen
A
Roseborough
James W
JW
Saint
Sanjay
S
Underwood
Willie
W
Murphy
Hedwig S
HS
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