Beyond root cause analysis: a practical systems engineering approach to incident investigation in histopathology

Patient safety and diagnostic quality are central to modern histopathology practice. Current incident investigation approaches often rely on root cause analysis; however, its routine use as a universal method is insufficient to address the highly variable, cognitive, sociotechnical and multifactorial nature of histopathology errors. In practice, incidents range from simple technical failures to complex system-level events requiring distinct investigative strategies. A key limitation of current practice is the lack of proportionality, where similar methods are applied irrespective of case complexity. In addition, corrective actions frequently target the immediate error without adequately considering the broader system context, potentially increasing workload, introducing new risks or degrading long-term service performance and operational sustainability. In this narrative review, we propose a practical five-stage systems framework for incident management in histopathology. This framework integrates proportional incident classification, structured systems investigation, prospective evaluation of corrective actions to minimise unintended consequences, implementation of system-level improvements and continuous performance monitoring. By selectively applying established human factors and quality improvement methodologies according to incident complexity, the framework shifts incident management from retrospective error investigation towards proactive system optimisation and continuous organisational learning. Ultimately, it provides a practical, scalable approach that improves diagnostic reliability, reduces recurrence, enhances efficiency and ensures that corrective actions are effective, sustainable and aligned with real-world laboratory practice.