College of American Pathologists
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CAP Today




July 2009

bullet Avoidable error

Errors are an intrinsic attribute of human endeavors, including the practice of medicine. Unfortunately, some are unavoidable, but the category of avoidable errors should be the focus of intense efforts by physicians. The report from Ossama Tawfik, MD, PhD, and Mark Redick, MD, PhD, at Kansas University Medical Center, correlating radiologic and pathologic findings in breast biopsies, is an important step toward minimizing avoidable errors. It is also a gratifying example of interspecialty collaboration in the interests of improving patient care.

Aristotle knew that the impact of an error that occurs early in a process is magnified as the process unfolds: “The least initial deviation from the truth is multiplied later a thousandfold.” Mammography, typically the first step in breast cancer detection, thus warrants very close attention, obviously from radiologists but also from the other downstream physicians. Certain features of contemporary practice increase the potential for faulty communication between specialists: The specialists are often in different facilities and often rely exclusively on each other’s written reports. Every practicing pathologist knows that simply reading an imaging report can lead to serious misinterpretations. The system developed by Drs. Tawfik and Redick, videoconferencing with digital mammographic and pathologic capabilities, offers a way around these difficulties using technology that is already well developed and available to the practice community. Assuming that their impressive results can be repeated by others (106 patients examined, 42 of whom had at least a minor nonconcordance and 14 of whom had a major nonconcordance), these data demand attention from all pathologists and radiologists who deal with breast biopsies, and should be a powerful force for increased usage of such videoconferencing capabilities.

(Disclosure: I am an alumnus of Kansas University Medical School [1962] and its residency program. For many years I have held a volunteer (unpaid) appointment as clinical professor of pathology at Kansas University Medical School Wichita. I am retired and have no connection with the work reported in CAP TODAY.)

Dwight K. Oxley, MD,
Wichita, Kan.