title: Interpretive Diagnostic Error Reduction in Surgical Pathology and Cytology: Guideline From the College of American Pathologists Pathology and Laboratory Quality Center and the Association of Directors of Anatomic and Surgical Pathology.
abstract: BACKGROUND
  Additional reviews of diagnostic surgical and cytology cases have been shown to detect diagnostic discrepancies.
  
  
  OBJECTIVE
  To develop, through a systematic review of the literature, recommendations for the review of pathology cases to detect or prevent interpretive diagnostic errors.
  
  
  METHODS
  The College of American Pathologists Pathology and Laboratory Quality Center in association with the Association of Directors of Anatomic and Surgical Pathology convened an expert panel to develop an evidence-based guideline to help define the role of case reviews in surgical pathology and cytology. A literature search was conducted to gather data on the review of cases in surgical pathology and cytology.
  
  
  RESULTS
  The panel drafted 5 recommendations, with strong agreement from open comment period participants ranging from 87% to 93%. The recommendations are: (1) anatomic pathologists should develop procedures for the review of selected pathology cases to detect disagreements and potential interpretive errors; (2) anatomic pathologists should perform case reviews in a timely manner to avoid having a negative impact on patient care; (3) anatomic pathologists should have documented case review procedures that are relevant to their practice setting; (4) anatomic pathologists should continuously monitor and document the results of case reviews; and (5) if pathology case reviews show poor agreement within a defined case type, anatomic pathologists should take steps to improve agreement.
  
  
  CONCLUSIONS
  Evidence exists that case reviews detect errors; therefore, the expert panel recommends that anatomic pathologists develop procedures for the review of pathology cases to detect disagreements and potential interpretive errors, in order to improve the quality of patient care.
authors.affiliation: From the Department of Laboratory Medicine and Pathology, Mayo Clinic, Jacksonville, Florida (Dr Nakhleh); the Department of Pathology, Massachusetts General Hospital, Boston (Dr Nosé); Governance (Ms Colasacco) and the Pathology and Laboratory Quality Center (Mss Fatheree and Ventura), College of American Pathologists, Northfield, Illinois; Hospital Pathology Associates, Abbott Northwestern Hospital, Minneapolis, Minnesota (Dr Lillemoe); the Department of Medicine, Duke University, Durham, North Carolina (Dr McCrory); the Department of Pathology and Laboratory Medicine, Henry Ford Health System, Detroit, Michigan (Dr Meier); the Department of Pathology, Baystate Medical Center, Springfield, Massachusetts (Dr Otis); the Department of Pathology, University of Michigan Medical School, Ann Arbor (Dr Owens); the Department of Pathology, Memorial University of Newfoundland/Eastern Health Authority, St John's, Newfoundland, Canada (Dr Raab); the Department of Pathology, St John's Health Center, Santa Monica, California (Dr Turner); and the Department of Pathology, Homestead Hospital, Homestead, Florida (Dr Renshaw). Dr Meier is currently with the Department of Pathology, Massachusetts General Hospital, Boston.
authors.forename: Raouf E
authors.initials: RE
authors.lastname: Nakhleh
authors.forename: Vania
authors.initials: V
authors.lastname: Nosé
authors.forename: Carol
authors.initials: C
authors.lastname: Colasacco
authors.forename: Lisa A
authors.initials: LA
authors.lastname: Fatheree
authors.forename: Tamera J
authors.initials: TJ
authors.lastname: Lillemoe
authors.forename: Douglas C
authors.initials: DC
authors.lastname: McCrory
authors.forename: Frederick A
authors.initials: FA
authors.lastname: Meier
authors.forename: Christopher N
authors.initials: CN
authors.lastname: Otis
authors.forename: Scott R
authors.initials: SR
authors.lastname: Owens
authors.forename: Stephen S
authors.initials: SS
authors.lastname: Raab
authors.forename: Roderick R
authors.initials: RR
authors.lastname: Turner
authors.forename: Christina B
authors.initials: CB
authors.lastname: Ventura
authors.forename: Andrew A
authors.initials: AA
authors.lastname: Renshaw
mesh_terms: D006801:Humans; D003581:Cytodiagnosis / Q000592:standards; D003951:Diagnostic Errors / Q000517:prevention & control; D007753:Laboratories / Q000592:standards; D010340:Pathology, Surgical / Q000592:standards; D000078202:Systematic Reviews as Topic