Learning to improve safety: false-positive pathology report results in wrongful surgery.

Marcia M. Piotrowski, Roland L. Bessette, Stephen Chensue, Daniel Cutler, Allen Kachalia, James W. Roseborough, Sanjay Saint, Willie Underwood, Hedwig S. Murphy

Research output: Contribution to journalArticlepeer-review

Abstract

BACKGROUND: A patient experienced a wrongful surgical resection, specifically, a radical retropubic prostatectomy because of a false-positive pathology report. FINDINGS FROM THE ROOT CAUSE ANALYSIS (RCA): 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. RECOMMENDATIONS: 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. TRACKING COMPLIANCE: 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.

Original languageEnglish (US)
Pages (from-to)123-131
Number of pages9
JournalJoint Commission journal on quality and patient safety / Joint Commission Resources
Volume31
Issue number3
DOIs
StatePublished - Mar 2005
Externally publishedYes

ASJC Scopus subject areas

  • Leadership and Management

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