Classification of error in anatomic pathology: a proposal for an evidence-based standard

Area of Science:

• Pathology
• Medical Error Analysis
• Diagnostic Science

Background:

• Error in anatomic pathology (EAP) is a complex issue, often addressed without a clear understanding of its pathogenesis.
• Historical approaches to medical and diagnostic errors have sometimes been ineffective or harmful, akin to 'bleeding and purging' or 'blaming and shaming'.

Purpose of the Study:

• To propose a theoretically-sound taxonomic system for classifying errors in anatomic pathology.
• To enable evidence-based categorization of individual EAP cases.
• To distinguish between individual, small system, and large system factors contributing to diagnostic errors.

Main Methods:

• Analogy to the medical disease model for understanding EAP.
• Development of a valid taxonomy to group abnormalities by pathogenesis.
• Parsing the broad concept of 'error' into meaningful subcategories.

Main Results:

• A proposed taxonomic system for classifying EAP.
• Distinction between knowledge-based interpretative (KBI) errors and other error types (e.g., human lapses).
• Identification of the need to differentiate individual, small system, and large system error sources.

Conclusions:

• A robust taxonomy is the first step in addressing EAP using a disease model.
• Effective EAP countermeasures require understanding error pathogenesis and distinguishing error types and sources.
• The pathology specialty group must lead the initiative for recognizing the need and implementing EAP countermeasures.