Abstract:

In dermatology clinics, clinicians perform skin biopsies for diagnostic assistance and send them to the dermatopathology lab. Specimens are subsequently processed, reviewed under the microscope, given a diagnosis, and a report is generated which the clinicians review for patient care. At every step, there is a risk for error that can cause significant impact at the patient level. Currently, there is a paucity in the literature of studies assessing dermatopathology laboratory-specific errors. The aim in this study is to prospectively identify and characterize errors that are occurring at each step within a single academic institution. Lab errors were recorded from July 2021 to June 2022, spanning a total of 25,662 specimens. During this 1-year period, 180 known errors were recorded (0.7% error rate). The most common mistakes were incorrect biopsy site (36.1%), incorrect entry of a correct diagnosis (13.3%), incorrect patient information (10.6%), specimen mix-up (10.0%), and incorrect diagnosis (7.8%). Sources of error were traced to the submitting clinic (32.8%), the pathologist/fellow (23.3%), the histotechnician (20.0%), and information & technology (IT) (3.9%). Pre-analytical errors were most common (67.2%), followed by post-analytical (24.4%) and analytical errors (8.3%). An overwhelming number of errors were secondary to slips (attention errors, 87.2%) versus lapses (memory/omission errors, 7.2%). The most common scenario involved an incorrect biopsy site at the clinical level, recognized by the submitting clinician, and ultimately corrected with an amendment. Patterns in error detection vary between institutions, but identifying and characterizing these errors is essential for improving the workflow to minimize them. Increasing the automation of tasks and decreasing transfers in communication are potential solutions to help reduce the error rate in dermatopathology labs and limit delays and errors in patient care.

Financial Disclosure:
No current or relevant financial relationships exist.

Simo Huang

Affiliation

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Errors Encountered in the Dermatopathology Laboratory