Diagnostic 'Errors' in a Single Urogenital Pathology Unit

ABSTRACT

To understand better the factors that contribute to diagnostic errors in urogenital pathology units, as part of our ongoing research into urogenital cancers, from a consecutive series of 6304 histologic reports for the years 2003 to 2006 we selected for review those containing more than one evident error. We reviewed 1746 urogenital histopathologic diagnoses, 1459 (83.56%) referred to biopsies and 287 (16.43%) to surgical specimens. Of the 1746 reports reviewed, 1643 diagnoses (94.10%) were in agreement and 103 (5.89%) in disagreement with the reviewer’s rating. Among these 103 diagnoses, 77 (70.75%) had justifiable and 27 (26.21%) unjustifiable discordances. Of these 27 discordances, 23 were unjustifiable discordances containing errors with consequences that affected patient management. The poor diagnostic efficiency found in a single anatomopathological unit raises concern and suggests considerable room for improvement. Efficiency could be substantially improved if pathological services strictly applied the existing international measures for quality control.

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