College of American Pathologists
Printable Version

  Defining "error" from patient’s perspective





cap today

February 2006
PAP/NGC Programs Review

CAP Cytopathology Committee*

I and the co-authors of the Cancer article thank the members of the CAP Cytopathology Committee for their thought-provoking article. As the members point out, the study of medical error is a challenge, and researchers disagree even on the definition of medical error. We accept the Institute of Medicine definition of error as "the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim." Applying this to diagnostic testing is not straightforward, and we consider that a diagnostic testing error is one in which the interpretation rendered is not descriptive of the actual pathologic process in the patient. We choose to look at the entire testing pathway and recognize that the pathology processes compose only a portion. Our root-cause analytic studies indicate that it often is difficult to identify the specific processes that fail when a diagnostic error occurs. The example provided by the members of the CAP Cytopathology Committee highlights this issue. In this scenario, a patient undergoes a fine needle aspiration of a sclerotic lung nodule that shows only scant benign fibrous tissue and the subsequent excisional biopsy shows malignancy. The committee members wrote, "[M]any reasonable individuals would not consider this an error," and "There was no interpretive error by the cytopathologist...." Perhaps. However, using the Institute of Medicine definition, an error occurred because there was a failure in the test to reach the diagnosis. Errors are defined from the patient perspective and not on the root-cause analytic adjudication process that separates errors into interpretation or sampling. In some cases, the root cause of the error may be sampling factors such as radiologist experience or patient-related-factors that are beyond the control of the physicians involved in the care management. We believe that these issues need to be better studied and that pathologists have a key role in determining why these errors occur and in decreasing the frequency of error.

Stephen Raab, MD
Department of Pathology
University of Pittsburgh Medical Center
Shadyside Hospital

* Members of the CAP Cytopathology Committee are David C. Wilbur, MD, chair; Joel S. Bentz, MD; Christine Noga Booth, MD; Karen M. Clary, MD; Amy C. Clayton, MD; Camilla J. Cobb, MD; Terence J. Colgan, MD; Teresa M. Darragh, MD; Barbara S. Ducatman, MD; Michael R. Henry, MD; Nicholas J. Hruby, MD; Jonathan H. Hughes, MD, PhD; Gladwyn Leiman, MBBCh; Ann T. Moriarty, MD; Marianne Unger Prey, MD; Mary R. Schwartz, MD; William D. Tench, MD; Theresa M. Voytek, MD; Patricia G. Wasserman, MD; Nancy A. Young, MD; Maureen F. Zakowski, MD; and Sarah E. Rollins, MD.

bullet Related Links