title: Errors in Surgical Pathology Reports: a Study from a Major Center in Pakistan.
abstract: BACKGROUND
  Errors in surgical pathology diagnosis can have serious consequences for the patient. Since the final product of a surgical pathology lab is the report, errors can be picked by reviewing reports of cases.
  
  
  OBJECTIVE
  To determine the frequency and types of error in surgical pathology reports of cases signed out in 2014 in a laboratory in Karachi, Pakistan.
  
  
  METHODS
  All surgical pathology reports in which changes were made in the original report after sign out and an amended report was issued were included. Errors included: (1) misinterpretations; (2) missing critical information; (3) erroneous critical information; (4) misidentification; and (5) typographic errors.
  
  
  RESULTS
  Errors were identified in 210 cases (0.37%). These comprised 199 formalin fixed specimens and 11 frozen sections. The latter represented 3.8% of a total of 2,170 frozen sections. Of the 11 frozen section errors, 10 were misinterpretations. Of the 199 permanent specimens, 99 (49.7%) were misinterpretations, 65 (32.7%) belonged to missing critical information category, 8 (4%) belonged to erroneous critical information category, 8(4%) were misidentifications, 16(8%) were typographic errors while 3 cases (1.5%) were other errors. Most misinterpretations occurred in the gastro intestinal, liver and pancreato biliary tract (23.2%) and breast (13.1%). Another 87 cases were reviewed on the clinicians' request. However diagnosis after review remained the same as the original diagnosis. In 49 out of these (56.3%), additional workup was performed at the time of the review.
  
  
  CONCLUSIONS
  Our findings were similar to other published studies. We need to develop documented procedures for timely review of cases to detect errors.
authors.affiliation: Pathology and Laboratory Medicine, Histopathology, Aga Khan University Hospital, Karachi, Pakistan E-mail : zubair.ahmad@aku.edu.
authors.forename: Zubair
authors.initials: Z
authors.lastname: Ahmad
authors.forename: Romana
authors.initials: R
authors.lastname: Idrees
authors.forename: Nasir
authors.initials: N
authors.lastname: Uddin
authors.forename: Arsalan
authors.initials: A
authors.lastname: Ahmed
authors.forename: Saira
authors.initials: S
authors.lastname: Fatima
mesh_terms: D003951:Diagnostic Errors / Q000517:prevention & control / Q000706:statistics & numerical data*; D005629:Frozen Sections / Q000379:methods* / Q000592:standards; D006801:Humans; D009367:Neoplasm Staging; D009369:Neoplasms / Q000175:diagnosis* / Q000453:epidemiology; D010154:Pakistan / Q000453:epidemiology; D010340:Pathology, Surgical / Q000379:methods* / Q000592:standards; D011379:Prognosis; D011785:Quality Assurance, Health Care; D011786:Quality Control