Errors encountered in the diagnostic pathway: A prospective single-institution study

Diagnostic pathways involve multiple steps from specimen collection to final pathology reporting. Prior research has shown that errors can occur at any stage, but the exact frequency and types remain unclear. While it was already known that pre-analytical errors are common, the specific distribution of responsibility among clinicians and lab staff was not fully characterized. This gap motivated a detailed examination of error types and their sources. No prior work had resolved the contribution of individual roles in diagnostic pathway errors. Understanding these patterns helps improve diagnostic accuracy and patient safety. This study aimed to clarify the nature and frequency of errors in a real-world setting. The findings may help institutions refine their diagnostic processes and training programs.

This study aimed to identify and characterize diagnostic pathway errors in dermatopathology. The specific problem was the lack of detailed data on error types and responsible roles. The motivation was to improve the diagnostic process by understanding where and how errors occur. The researchers focused on a single academic institution to ensure consistent procedures. The goal was to quantify error rates and determine the most frequent types. The study also aimed to assess the phase in which errors most commonly occurred. Understanding these factors could lead to targeted interventions. The results may inform quality improvement initiatives in pathology labs.

The study used a prospective design over a 1-year period at a single academic institution. A total of 25,662 biopsy specimens were processed. Researchers recorded and categorized all errors that occurred during the diagnostic pathway. Errors were classified by phase: pre-analytical, analytical, or post-analytical. Each error was attributed to a specific role: clinician, dermatopathologist, or histotechnician. The most common error types were identified through frequency analysis. Data collection included error descriptions, locations, and responsible parties. The goal was to provide a detailed characterization of diagnostic pathway errors.

A total of 190 errors were recorded out of 25,662 specimens, resulting in an error rate of 0.7%. The most frequent error was an incorrect biopsy site (n = 65). Incorrect data entry of a correct diagnosis occurred in 25 cases. Specimen mix-up was reported in 23 instances. The pre-analytical phase accounted for 128 of the 190 errors. Clinicians were responsible for 34.2% of errors. Dermatopathologists accounted for 23.7% of errors. Histotechnicians were responsible for 18.9% of errors. Slips were the most common type of human error (n = 156).

The study found that the majority of diagnostic pathway errors occurred in the pre-analytical phase. Clinicians were the most frequent source of errors, followed by dermatopathologists and histotechnicians. Incorrect biopsy site selection was the most common error type. Over two-thirds of errors occurred before the slide reached the dermatopathologist. Diagnostic errors in the analytical phase were rare. When diagnostic errors occurred, clinicians were most likely to detect them. The authors suggest that examining and addressing these common errors can lead to quality improvement. The findings may inform targeted interventions to reduce error rates in dermatopathology.