Lessons from a Review of Amended Reports for Quality Assurance in Breast Pathology

Abstract:

The literature on quality assurance and peer-review processes in surgical pathology is extensive, however, the majority of these papers apply to general surgical pathology. We focused on the peer-review reporting system of a women’s health pathology clinic that specialized in breast and gynecologic pathology, with the explicit goal of discovering diagnostic differences that impacted patient treatment.

Methods:

Quality metrics are tracked in this specialized practice, and any amended/corrected reports are reviewed by the Medical Director. Error kinds are qualitative and are classified based on their influence on patient care. As a measure of error kind and frequency, QA data from all revised reports in breast and gynecologic pathology from 2012 to 2014 were analyzed.

Results:

343 specimens (0.54% of all reports) required revision due to a QA metric-discovered disparity during this time period. Breast specimens had a higher rate of amendment than GYN specimens (1.14% of breast specimens versus 0.27% of GYN specimens). Type A, or Minor Disagreement, was the most common mistake type necessitating an amendment for both breast and GYN specimens (reports altered for type A discrepancy: 78.7% of the total; 81.9% of the breast; 72.6% of GYN). Type B, or Moderate Disagreement inconsistencies, accounted for 21.3% of all revised instances (18.1% of the breast; 27.3% of GYN). There were no cases classified as type C, or Major Disagreements, among all breast and GYN, reports analyzed during the QA study.

Conclusion:

When surgical pathology is performed in a laboratory under strict quality assurance standards, major diagnostic interpretation errors are unlikely. The technique reduces mistakes, improves patient safety, and offers pathologists real-time instructional opportunities.

Patient therapy is guided by surgical pathology diagnoses, hence accurate diagnostic interpretation is crucial for optimal patient management. The public was taken aback when recently released information on diagnostic disputes among pathologists examining breast biopsy specimens revealed a roughly 25% discordance rate among pathologists participating in the study, particularly in atypia diagnosis. Unfortunately, in a non-CLIA lab research environment, this study was not representative of true pathology practice and provided deceptive statistics. As a result of this research, we decided to examine our own QA data to establish the prevalence of diagnostic discrepancies (as determined by the review of revised reports) in breast and GYN pathology at our institution. Comprehensive quality assurance processes are used at our university Women’s Hospital to detect and correct serious diagnostic issues.

Laboratory medicine is a highly structured profession in which accuracy and safety have been regularly assessed and regulated for decades. Pathologists use a variety of diagnostic tools and consultations in forming a diagnostic judgment to provide diagnostic information to other clinicians, such as access to the patient’s electronic medical record, access to radiographic images, submission of additional tissue levels, specialized immunohistochemical stains, access to prior related specimen slides, and, in some cases, submission of additional tissue. Importantly, after a diagnosis is made using these methods, the case material is routinely re-evaluated using multiple QA measurements. These QA procedures are used by practicing laboratories for more than only reducing diagnostic errors.

Methods and Design:

In this study, we reviewed QA data on intradepartmental reports that required an amendment to analyse the frequency and severity of errors in breast and gynecologic (GYN) pathology specimens.

At our institution, quality assurance/peer review protocols include 10% intradepartmental random case review, frozen section/permanent section diagnosis correlation, intradepartmental consensus conference review, review of cases presented at multidisciplinary tumor boards, double independent reads of all breast core biopsies and all new malignancies prior to signing out, and review of prior biopsy materials.

Concurrently with surgical resections, and real-time Cytohistologic correlations. In addition, all cases that are sent to outside institutions by patient request have incoming reports that are reviewed by the Chief of service, and pathologists are required to issue addendum reports that state their report was reviewed by an outside institution and diagnosis was in agreement. If a diagnosis is not in agreement with an outside institution, the case is then reviewed by the Chief of service to adjudicate the diagnosis with further exterior consultation if necessary.

The peer review processes are all monitored by the Chief of service, who also serves as the head of the departmental quality assurance committee. The Chief, in concert with the QA manager, initiates the production of an amended report if the criteria for an amended report are met as described below, and the Chief assigns an error severity based on the reported defect and how it impacts patient care. Impact on patient care is determined individually for each case, taking into account the pathology report result, clinical information supplied electronic medical record information, and clinician input.

The degree of errors in modified reports is denoted as follows: A — Minor disagreement, such as a typo or a formatting problem that had no influence on medical treatment; B — Moderate Disagreement, including diagnostic flaws/omissions that would not result in a change in patient care, Type B errors are report deficiencies that may include erroneous information, such as omission errors, missed lymphovascular invasion, or wrong grading of breast cancer. Such errors would not demand a change in patient care at our facility. Type C errors represent a significant disagreement, which includes severe diagnostic inconsistencies that would be deemed a critical event warranting a modification in a patient’s treatment plan.

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· https://medium.com/@elizaedwards2021/10th-world-breast-pathology-and-breast-cancer-conference-6db6e4fc81c2

· https://kikoxp.com/posts/11632

· https://www.quora.com/profile/BreastCancerUCGConferences/10th-World-Breast-Pathology-and-Breast-Cancer-Conference-Dear-colleagues-and-guests-welcome-to-the-10th-World-Breast-Pa

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· https://www.reddit.com/user/breastcancerucg1/comments/taq1kt/10th_world_breast_pathology_and_breast_cancer/

· https://www.blogger.com/blog/post/edit/3238443600245550728/7246086302346767315

· 10th World Breast Pathology and Breast Cancer Conference | LinkedIn

· https://medium.com/@elizaedwards2021/10th-world-breast-pathology-and-breast-cancer-conference-6886c15ccb37

· https://wordpress.com/post/breastpath2022.wordpress.com/6

· https://medium.com/@elizaedwards2021/breast-cancer-disease-f0324f19b8a2

· https://www.blogger.com/blog/posts/3238443600245550728